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Private and voluntary organisations · Company
First report 12 Mar 2020•Latest report 12 Mar 2020
Reports naming this recipient by issue year.
* 2026 is projected from reports observed to 7 Sep 2026.
Naming this recipient
Found for named reports
Across all linked responses
Described in responses
Statements from Physio-Control UK Sales Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.
East London
The concerns inaccurately reflect LP15 capabilities because it can be configured to power on in either automatic or manual defibrillation mode.
Existing LP15 configuration capability is considered sufficient, so no action is proposed in relation to the report.
AI-generated summary
This summary was generated using AI from the published report. Please read the original report for the complete account.
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
Source evidence
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Physio-Control UK Sales Ltd; that does not assign responsibility.
Failure to review the defibrillator during resuscitation
“The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm. Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events. Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient. This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use. 2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%. The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance. If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided. I understand that procurement decisions regarding the future supply of defibrillators are imminent. ”
LP15 defibrillator defaulting to manual mode
Failure to activate the LP15 defibrillator in automatic mode
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
“After consultation with the manufacturer of the LP15 device, I can advise that the LP15 monitor/defibrillator is designed with the ability to be configured to power on in either automatic or manual defibrillation mode based on the clinical protocols of the health system. Accordingly, I respectfully submit that the Coroner’s Concerns listed at Section 5 of the Report do not accurately reflect the capabilities of the LP15 device.”
2020-0066-Response-from-Stryker-Corporation-Physio-Control-RedactedPage 1 · responsePublished 27 March 2020
“Due to the existing capability of the LP15 to be configured to power on in either automatic or manual defibrillation mode, Stryker does not propose to take any action in relation to the 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
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