Recipient

London Bridge Hospital

First report 3 Feb 2017•Latest report 3 Feb 2017

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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: 4
Stated actions: 17

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

17stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from London Bridge Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Feb2017
London Inner (South)
Concerns raised4
1. Delays in communicating suction catheter difficulties to doctors
2. Delays in identifying and replacing blocked endotracheal tubes
3. Failure to monitor humidifier operation and temperature
1. Lack of a humidifier alarm indicating when the machine is turned off
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Revise the Cardiac Arrest Record Checklist to prompt capnography and DOPES.
  Stated completed
2. Action
  Deliver ongoing advanced airway, simulation, mock-arrest and blocked-tube training for intensive care staff.
  Stated in progress
3. Action
  Use the Cardiac Arrest Record Checklist during arrests and audit and review post-arrest debrief records.
  Stated completed
1. Action
  Require continuous capnography for all ventilator-dependent critically ill patients and extend emergency availability with portable monitors.
  Stated completed
2. Action
  Adopt SBAR to standardise early verbal escalation and critical information-sharing during emergencies.
  Stated completed
3. Action
  Implement DOPES airway assessment and embed it in cardiac arrest training and the Cardiac Arrest Record Checklist.
  Stated completed
4. Action
  Review critical care courses and introduce capnography, SBAR and DOPES where previously absent.
  Stated completed
5. Action
  Train ICU clinical staff to interpret capnography through induction courses, competency materials and recurring Learning Academy training.
  Stated completed
Respondent positions 2
1. Position
  Action on concern 2 is assigned to Fisher and Paykel; LBH considers itself not required to act because it is not responsible.
  Redirects responsibility
1. Position
  Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.
  Redirects responsibility
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 London Bridge Hospital; 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 London Bridge Hospital; 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 London Bridge Hospital; 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 London Bridge Hospital; 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
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
Revise the Cardiac Arrest Record Checklist to prompt capnography and DOPES.

Verbatim wording from the response
“c. The Cardiac Arrest Record Checklist has been revised to include prompts for capnography and DOPES (see B.3 below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 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
Deliver ongoing advanced airway, simulation, mock-arrest and blocked-tube training for intensive care staff.

Verbatim wording from the response
“f. HCA and the Simulation and Interactive Learning (“SaIL”) Centre at Guy’s and St Thomas’ Foundation Trust have collaborated to deliver additional Intensive Care Airway training for intensive care staff (medical and nursing) working within LBH intensive care environments. This is an ongoing programme of training.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 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
Use the Cardiac Arrest Record Checklist during arrests and audit and review post-arrest debrief records.

Verbatim wording from the response
“a. The Cardiac Arrest Record Checklist is completed by the scribe (this is generally the Duty Manager) who will prompt the cardiac arrest team on capnography, SBAR and DOPES if necessary during the arrest.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 6 · response
Published 19 February 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
Require continuous capnography for all ventilator-dependent critically ill patients and extend emergency availability with portable monitors.

Verbatim wording from the response
“The following steps have been implemented in relation to equipment, training and human factors relevant to the Coroner’s concerns:”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 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
Adopt SBAR to standardise early verbal escalation and critical information-sharing during emergencies.

Verbatim wording from the response
“LBH has adopted the following strategies.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 6 · response
Published 19 February 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
Implement DOPES airway assessment and embed it in cardiac arrest training and the Cardiac Arrest Record Checklist.

Verbatim wording from the response
“e. LBH has also implemented DOPES (see B.4 below), a system of assessment and diagnosis to be followed by staff in a situation where a suspected “difficult airway” problem arises. DOPES has also been added to the Cardiac Arrest Record Checklist as a prompt for the cardiac arrest team’s scribe.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 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
Review critical care courses and introduce capnography, SBAR and DOPES where previously absent.

Verbatim wording from the response
“k. All the critical care courses offered by HCA (usually via a leading London university) have been reviewed and the roles of capnography, SBAR and DOPES introduced where they did not exist previously (see B.4 below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 4 · response
Published 19 February 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
Train ICU clinical staff to interpret capnography through induction courses, competency materials and recurring Learning Academy training.

Verbatim wording from the response
“b. Clinical staff working in ICU receive training in the interpretation of capnography (prior to commencing work in ICU) via courses (critical care, in-prep, and foundation) and via competency booklets. It is thereafter reinforced through a regular programme of training, implemented through the HCA Learning Academy (see A.2.2.b below).”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 3 · response
Published 19 February 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Action on concern 2 is assigned to Fisher and Paykel; LBH considers itself not required to act because it is not responsible.

Verbatim wording from the response
“Concern numbered (2) indicates that Fisher and Paykel (manufacturers of the humidifier) have the power to take action. LBH is not required to take action having already satisfied the Coroner that it is not responsible for addressing this concern.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 2 · response
Published 19 February 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.

Verbatim wording from the response
“Concern numbered (1) indicates that the Nursing and Midwifery Council (“NMC”) has the power to take action. LBH is not required to take action having already satisfied the Coroner that it is not responsible for addressing this concern.”

Source location
2017-0011-Response-by-London-Bridge-Hospital
Page 2 · response
Published 19 February 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

Delays in communicating suction catheter difficulties to doctors

Delays in identifying and replacing blocked endotracheal tubes

Failure to monitor humidifier operation and temperature

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

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.8

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 8

Respondent positions 2