Fisher & Paykel Healthcare Limited

Private and voluntary organisations · Private limited company

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First report 3 Feb 2017•Latest report 3 Feb 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Fisher & Paykel Healthcare Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. London Inner (South)

    AI-generated summary

    ROBERT ENTENMAN · 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

    Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.

    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 Fisher & Paykel Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in communicating suction catheter difficulties to doctors

    Wider context from the report

    “(3) 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. 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. ”
    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 Fisher & Paykel Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in identifying and replacing blocked endotracheal tubes

    Wider context from the report

    “(3) 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. 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. ”
    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 Fisher & Paykel Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor humidifier operation and temperature

    Wider context from the report

    “(1) Three nurses cared for Mr Entenman 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 handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier. ”
    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 Fisher & Paykel Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a humidifier alarm indicating when the machine is turned off

    Wider context from the report

    “(2) The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off. ”
    Open source report
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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