Recipient

Eschmann Holdings Limited

First report 19 Dec 2013•Latest report 19 Dec 2013

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: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Dec2013
Manchester West
Concerns raised6
1. Handset emergency stop buttons failing to operate independently when other handset parts are damaged
2. Inadequate staff training and auditing of pre-operative equipment checks
3. Pre-operation checks failing to assess handset function, condition, seals and position
1. Inspection procedures failing to identify handset damage and secure immediate replacement
2. Failure to share investigation information with interested agencies promptly
3. Failure to review operating tables and handsets used at the Hospital
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Kenneth Smalley · 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

Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.

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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Handset emergency stop buttons failing to operate independently when other handset parts are damaged
Wider context from the report
“(3) I have concerns with regard to the Eschmann Group in relation to a review of the operation of handsets attached to operating tables in view of the number of unexplained and uncontrolled movements of operating tables with particular reference to the isolation of the emergency stop button on the handsets to ensure that the emergency stop button operates in all circumstances when there is damage to other parts of the handset. ”
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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Inadequate staff training and auditing of pre-operative equipment checks
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Pre-operation checks failing to assess handset function, condition, seals and position
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Inspection procedures failing to identify handset damage and secure immediate replacement
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to share investigation information with interested agencies promptly
Wider context from the report
“(4) I have concerns with regard to the Medicines and Healthcare Products Regulatory Agency in relation to contact with all interested Agencies following an investigation to ensure the sharing of information with all interested Agencies particularly to enable lessons to be learned and corrective action to be taken as soon as possible. ”
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 Eschmann Holdings Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to review operating tables and handsets used at the Hospital
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
Open source report

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 raised6

Handset emergency stop buttons failing to operate independently when other handset parts are damaged

Inadequate staff training and auditing of pre-operative equipment checks

Pre-operation checks failing to assess handset function, condition, seals and position

Inspection procedures failing to identify handset damage and secure immediate replacement

Failure to share investigation information with interested agencies promptly

Failure to review operating tables and handsets used at the Hospital