“It spontaneously shut itself off.” Red Wing Fire Chief Tom Schneider
Earlier this month, several reports about the death of Janice Hall, a Red Wing, Minnesota woman came to light. Specifically, she died in an ambulance as a result of a software failure in the oxygen delivery system caused the system to abruptly shutdown. Apparently, the ambulance EMTs did not notice that the oxygen system had quit for a number of minutes, and thus Janice Hall unfortunately died.
At this time, details are sketchy, and according to news reports there's been no comments from Spartan Chassis, the parent company of the oxygen system manufacturer. Now, as we don't yet know what company's software controlled the faulty oxygen issue, I expect the details will emerge eventually.
But is "eventually" good enough? And what of the reporting of these kinds of issues? Is it incumbent upon the vendor to notify its customers, or do federal regulations and processes dictate a process? How does a party responsible for an ambulance with this type of system made aware of a potential failure?
To me, the most troubling aspect of this event is the prior failure of the oxygen system, and it's subsequent replacement, before the repeated failure of the new system that caused Janice Hall's death.
Rather than pointing to the software as the failure, perhaps the people driven process of replacing, testing and verification is the true root cause of failure in this situation?
1. IEEE Blog: http://tinyurl.com/27bj3km
2. Firefighter Close calls: http://tinyurl.com/27hwlgl
3. EMS1" http://tinyurl.com/39pxfa6