Mary Land

“The Philips Respironics AF 541 mask connects to the tubing, linking it to the BIPAP ventilator by means of a 'push on' connection (rather than a fitting involving positive engagement). Evidence taken at the Inquest indicates this connection has come undone on other occasions as well. The introduction of a filter at the site of this union increases the potential for the joint to come apart. Consideration should be given to installing a more robust docking mechanism which is less vulnerable to working”