19 Jun 2017 PATRICK NEIL WOODS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 4 Lack of knowledge of the equipment portfolio View source Ineffective training on equipment View source Failure to identify potentially dangerous equipment View source Failure to undertake risk assessments for equipment that could potentially kill a patient View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Make a training video specifically addressing ACGO-switch use for introductory and refresher training.
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Action
Update training materials to cover ACGO and COSY operation, ventilation modes, fresh-gas routing, monitored parameters, and hypoxic-mixture risks.
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Action
Contact UK Fabius customers to arrange Draeger site visits addressing concerns and further training needs within 16 weeks after the Field Safety Notice.
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AI-generated summary
PATRICK NEIL WOODS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
PATRICK NEIL WOODS was admitted to hospital with a cough, deteriorated while being treated with a Dräger Tiro Anaesthetic Machine, suffered cardiac arrest, and died from hypoxic brain injury on 15 February 2016. Concerns included the hospital’s lack of knowledge about its equipment portfolio, inadequate risk assessment, and ineffective training that meant clinicians were not trained on, or did not recognise the risks of, the machine used.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Draeger Medical UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the equipment portfolio
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Draeger Medical UK Limited; that does not assign responsibility.
PFD Monitor interpretation Ineffective training on equipment
Wider context from the report “(1) The evidence of 4 clinicians at the inquest would suggest that the training by Dräger was not effective .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Draeger Medical UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify potentially dangerous equipment
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Draeger Medical UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk assessments for equipment that could potentially kill a patient
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a training video specifically addressing ACGO-switch use for introductory and refresher training.
Verbatim wording from the response “5. In further pursuit of achieving the objectives identified above, Draeger intends also to take the following steps:” Source location 2017-0434-Response-by-Draeger-Medical-UK-Limited
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update training materials to cover ACGO and COSY operation, ventilation modes, fresh-gas routing, monitored parameters, and hypoxic-mixture risks.
Verbatim wording from the response “4. Draeger recognises as a crucial priority the importance of optimising patient safety through optimising clinician competence regards the functionality of the machine. With those objectives in mind, Draeger has decided to take the following steps:” Source location 2017-0434-Response-by-Draeger-Medical-UK-Limited
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact UK Fabius customers to arrange Draeger site visits addressing concerns and further training needs within 16 weeks after the Field Safety Notice.
Verbatim wording from the response “b. The circulation worldwide of a Field Safety Notice (“FSN”) to hospitals for circulation amongst their anaesthetic departments drawing attention to the principles applicable to re-breathing circuit systems. Draeger will also send a copy of the FSN to electrical and biomedical engineering (EBME) bodies within each hospital within the UK to whom the FSN is sent. Draeger anticipates that the distribution of the FSN will begin from October 2017. Draeger will follow up the circulation of its FSN within the UK by seeking confirmation of receipt.” Source location 2017-0434-Response-by-Draeger-Medical-UK-Limited
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations