Source · Prevention of Future Deaths

Mark Kubiak

Ref: 2019-0098 Date: 22 Mar 2019 Coroner: Tom Osborne Area: Milton Keynes Responses identified: 0 / 1 View PDF

The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.

Date 22 Mar 2019

56-day deadline 17 May 2019

Responses identified 0 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: That the Thames Valley Transfer Network Checklist does not require the oxygen supply to be checked, or for a tug test to be completed at the time that the oxygen is transferred from the ward supply in the hospital to the portable cylinder. If such a check and test had been carried out, the failure of the oxygen flow to the patient would immediately have been noticed and the situation rectified. The checklist needs to be reviewed and updated to include the test suggested.

Report sections

Investigation and inquest

On 31/07/2018 I commenced an investigation into the death of Mark Stephen Anthony Simon KUBIAK aged 61. The investigation concluded at the end of the inquest on 11th March 2019. The narrative conclusion of the inquest was: The deceased suffered from acute necrotising pancreatitis and was cared for in the department of critical care at Milton Keynes University Hospital. On the 25th July 2018 it was decided to transfer him to the John Radcliffe Hospital in Oxford for surgical intervention. He was transferred to a portable ventilator and the oxygen supply was not connected properly and the lack of ventilation was not recognised. He suffered a cardiac arrest and died at 12:34 on 25th July 2018.

Circumstances of the death

The circumstances were that Mr Kubiak was being transferred from Critical Care at Milton Keynes Hospital to Intensive Care at the John Radcliffe Hospital. The Transfer network checklist was being followed but the checklist does not require the change of oxygen supply to be tested, or for a tug test to be carried out. When Mr Kubiak left the department the oxygen was not properly connected to the portable cylinder.

Action should be taken

7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17th May 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of Mr Kubiak South Central Ambulance Service Milton Keynes University Hospital Health Care Safety Investigation Branch The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. Tom OSBORNE Senior Coroner for Milton Keynes Dated: 22 March 2019

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0098
Date of report: 22 March 2019
Coroner: Tom Osborne
Coroner area: Milton Keynes

Responses identified

Responses identified 0 of 1

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 May 2019.

Sent to

Thames Valley and Wessex Operational Delivery Networks

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.