London Bridge Hospital

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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
100%

Found for named reports

Concerns addressed
4

Across all linked responses

Stated actions
17

Described in responses

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.

  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 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
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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