Plumber dies after being electrocuted as defibrillator in Co-op store 'unusable'
A plumber was electrocuted working on a house and a defibrillator from a nearby Co-op Central England store was found to be faulty, an inquest heard.
Mackenzie Cooper, 27, died as a result of cardiac arrhythmia induced by electrocution. A coroner is now demanding that action should be taken after a defibrillator brought from a Co-op store in Lindrick, near Worksop, to try and resuscitate him was unusable.
Following the inquest at Nottingham Coroners Court in July this year, a prevention of future deaths report has been written by Coroner Laurinda Bower, into the death of Mr Cooper, a qualified plumber who was sent to a residential property to deal with an emergency leak on September 29, 2022.
In the report, it states: "The electricity was turned off before Mackenzie arrived. The power was turned on to enable Mackenzie to vacuum up water. He was electrocuted when kneeling in water, he touched or came into close proximity to a copper pipe that was inadvertently carrying a live electrical current when the power was switched on."
This was due to the combination of two faults in the house electrical system. The occupier of the home called 999 and commenced CPR, whilst the homeowner fetched a community public access defibrillator from the Co-op store on Doncaster Road, Carlton in Lindrick, near Worksop.
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The device was provided by staff, but then when the device pack was opened it was found that there were no pads, and so could not be used, and this delayed the administration of a shock. An ambulance arrived after 20 minutes due to a delay in resource availability, but there is no evidence this contributed to the death as Mackenzie was already asystole when crews arrived, and was pronounced deceased at the scene at 3:34pm.
However, it was noted in the report that "there was no evidence these factors contributed to his death as he was already asystole when ambulance crews arrived." Asystole is when your heart's electrical system fails, causing your heart to stop pumping - sometimes known as 'flat-lining'.
When the occupier later returned the defibrillator to the store, staff members informed them that they knew the device was missing the pads as they had not been replaced since it was last used. If the ambulance service had known the device was unusable, they could have told the occupier the location of another nearby device, reported NottinghamshireLive.
Coroner Bower stated in the report: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."
Her matters of concern for Central England Co-operative include how the device was supplied to a member of the public in a non-workable condition, and how there appears to be no system for replacing the pads between uses. She is also concerned that there is either a training or communication issue as staff knew that the pads were missing, but supplied the device anyway.
Additionally, her concerns for the Department for Health and Social Care stated: "In December 2022, the Government committed to making available over £1 million for the purchase of more community public access defibrillators, in recognition of the fact that these devices have the potential to save lives.
"I am concerned that without a clear system for ensuring (a) the maintenance and good order of all community public access defibrillators, and (b) a system for sharing with all ambulance Trusts the current status of defibrillators i.e. when they are out of service due to missing parts/maintenance, members of the public might be directed to a device that cannot be used, as in this case."
A spokesperson for the Department of Health and Social Care has since stated: "Quick access to a defibrillator can be lifesaving when someone is experiencing cardiac arrest and we are committed to increasing the number of defibrillators in public areas. We recently announced funding to provide around 1,000 new defibrillators in community spaces across England and all state schools now have access to an on-site defibrillator.
"We have also written to local authority leaders urging them to ensure defibrillators in their area are registered on The Circuit - the national defibrillator network operated by the British Heart Foundation."
A spokesperson for Central Co-op stated: "Our thoughts are with the family and friends of Mr Cooper. We acknowledge the upset and sadness his tragic death at such a young age will have caused. We aim to positively contribute to the communities we are privileged to serve, and over the last few years have worked to provide public access defibrillators across many of our stores and funeral homes. We have worked in line with Ambulance Service guidance with regards to implementation and operational checks.
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"A full internal investigation has been carried out to ensure this does not happen again. We have introduced new, enhanced training and guidance for all operational colleagues. We have also increased the frequency of defibrillator checks, from the suggested once per month to weekly."
Judy O'Sullivan, Director of Innovation in Health Programmes at the British Heart Foundation (BHF), said: "We are very sorry to hear of this incident, and would like to extend our deepest sympathies to the family and friends of the man who sadly lost his life. CPR and defibrillation can be the difference between life and death in a cardiac arrest. We urge anyone who looks after a defibrillator to make sure that the device is kept in good working order, replacing batteries and pads when needed."
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