Christopher Osland
22 Feb 2022 · Coroner Kate Thomas · North East Kent
The coroner's concerns
1. room monitor volume reduced to inaudible level
“Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room - as a result, the volume of the room alarm was not part of hand over equipment checks.”
2. lack of documentation of monitor settings
“The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced”
3. OFF COMS alert not reconnected
“After silencing the 'OFF COMS' alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor”
4. persistent OFF COMS notification ignored
“No steps had been taken to respond to the 'OFF COMS' notification on the central monitor screen which had persisted for the 5 days prior to the 26th April 2021”
5. unclear response to OFF COMS alert
“It was unclear what steps nurses were supposed to take when confronted with an 'OFF COMS' alert or screen notification”