Recipient

Draeger Medical UK Limited

First report 19 Jun 2017•Latest report 19 Jun 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 6

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Draeger Medical UK Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

19 Jun2017
Bedfordshire and Luton
Concerns raised4
1. Lack of knowledge of the equipment portfolio
2. Ineffective training on equipment
3. Failure to identify potentially dangerous equipment
1. Failure to undertake risk assessments for equipment that could potentially kill a patient
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Make a training video specifically addressing ACGO-switch use for introductory and refresher training.
  Stated planned
2. Action
  Update training materials to cover ACGO and COSY operation, ventilation modes, fresh-gas routing, monitored parameters, and hypoxic-mixture risks.
  Stated completed
3. Action
  Contact UK Fabius customers to arrange Draeger site visits addressing concerns and further training needs within 16 weeks after the Field Safety Notice.
  Stated planned
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.

Read the report on judiciary.uk
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
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
Page 4 · response
Published 19 June 2017
Open published response
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
Page 2 · response
Published 19 June 2017
Open published response
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
Page 3 · response
Published 19 June 2017
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Lack of knowledge of the equipment portfolio

Ineffective training on equipment

Failure to identify potentially dangerous equipment

Failure to undertake risk assessments for equipment that could potentially kill a patient

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

Actions described in response 3