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Mark Kubiak

22 Mar 2019 · Coroner Tom Osborne · Milton Keynes
Check this reportOriginal

The coroner's concerns

  1. 1. oxygen supply not tested during transfer

    “the checklist does not require the change of oxygen supply to be tested, or for a tug test to be carried out”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error