Robert Entenman

3 Feb 2017 · Coroner Henrietta Hill QC · London Inner (South)

The coroner's concerns

1. humidifier turned off without detection
“Three nurses cared for Mr [name redacted] between 12.00pm on 22 May 2015 and 6.00am on 23 May 2015. During that time they did not observe that the humidifier had been turned off, either at the handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier.”
2. humidifier turned off without alarm
“The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off.”
3. endotracheal tube blockage not identified promptly
“There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier. There may have been further such delays after 6.00 am.”
4. nursing staff delayed reporting suction catheter difficulties
“There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.”