An inquest dealing with the case of an elderly man, who died in an ambulance engulfed by fire within four to six seconds of a flame coming out of a medical oxygen cylinder, has returned a verdict of accidental death.
It seemed “as if they were coming from a flame-thrower”, a paramedic who was in the ambulance with Christopher Byrne (79) outside Naas General Hospital in 2016 told the jury.
Along with its verdict, the jury asked that the use of medical compressed oxygen cylinders be reviewed to minimise the effects of heat build-up in the cylinder valve and that adequate firefighting equipment be available in ambulance bases.
Stephen Lloyd, a paramedic who was in the ambulance with Mr Byrne when it arrived outside the hospital, told the inquest that after he connected tubing to a portable oxygen cylinder and turned it on, he turned back around and it was “in flames”.
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They were coming from an area where the tube was connected and the top of the cylinder like a “flame-thrower”, he said.
The blankets caught fire immediately, he said. He tried to help get the patient out but the fire and heat were too great. He could not get to him and suffered burns to his own face and arms.
The ambulance driver, he believed, had pulled him out. “It was an awful terrifying experience and I never witnessed anything like it in my life”.
The driver, David Finnegan, an advanced paramedic, said after he left the portable cylinder on Mr Byrne’s trolley, he turned to leave and heard “a click and a pop” which was “not the norm”.
He said there was thick black smoke and a lot of problems trying to get the patient out. “I knew the poor man was gone,” he said.
Such cylinders were authorised for use by the Health Products Regulatory Authority. Millions of are used worldwide and no other such fatality has been recorded here or in the UK, although there was one in Poland during the Covid pandemic.
The inquest was told by Vincent Darcy, an inspector with the Health and Safety Authority (HSA) that since the death of Mr Byrne the valve on the type of cylinder involved has been surrounded with a brass ring to absorb heat.
UK fire investigations expert Aubrey Thyer, having reviewed the evidence, concluded the fire started inside the cylinder valve.
He found a link could be made between the seven previous known ignitions before the Naas incident. For reasons including the severe fire damage to the cylinder, he could not say conclusively how the Naas fire, or other fires, had started.
Given the overall rarity of fires in the combination valves, however, it was likely no single failure can lead to a fire alone, he said.
Represented by barrister John Kennedy SC, instructed by Powderly Solicitors, several members of Mr Byrne’s family attended the inquest in Athy Courthouse, Co Kildare, including his sons, Thomas and Christopher, and daughters, Sarah and Lil. Visibly upset during the hearing, the family declined to comment after the verdict.
Mr Byrne, who had had throat cancer and a trachea following previous surgery, had been taken to Naas hospital on September 22nd, 2016, with respiratory difficulties.
The inquest proceeded on Thursday before Kildare County Coroner Loretta Nolan and a seven member jury after the Director of Public Prosecutions (DPP) decided not to bring a prosecution earlier this year.
A Circuit Court case over mental distress arising from Mr Byrne’s death has also been initiated against the Health Service Executive (HSE); BOC Gases Ireland Ltd, as supplier of the oxygen cylinder; Luxfer Gas Cylinders Ltd as the manufacturer; and GCE Holdings AB, a Swedish registered company, as the valve manufacturer.
