Thames Valley and Wessex Adult Critical Care Operational Delivery Network

Health and care · Health-system partnership

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First report 22 Mar 2019•Latest report 22 Mar 2019

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 Thames Valley and Wessex Adult Critical Care Operational Delivery Network linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Milton Keynes

    AI-generated summary

    Mark Stephen Anthony Simon KUBIAK · 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

    Mark Stephen Anthony Simon KUBIAK suffered a cardiac arrest and died during transfer from Critical Care at Milton Keynes Hospital to the John Radcliffe Hospital on 25 July 2018. The oxygen supply to his portable ventilator was not connected properly, and the principal concern was that the transfer checklist did not require the oxygen supply to be checked or a tug test to be completed.

    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 Thames Valley and Wessex Adult Critical Care Operational Delivery Network; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the transfer checklist to require oxygen supply checks

    Wider context from the report

    “That the Thames Valley Transfer Network Checklist does not require the oxygen supply to be checked, or for a tug test to be completed at the time that the oxygen is transferred from the ward supply in the hospital to the portable cylinder. If such a check and test had been carried out, the failure of the oxygen flow to the patient would immediately have been noticed and the situation rectified. ”
    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 Thames Valley and Wessex Adult Critical Care Operational Delivery Network; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the transfer checklist to require tug tests

    Wider context from the report

    “That the Thames Valley Transfer Network Checklist does not require the oxygen supply to be checked, or for a tug test to be completed at the time that the oxygen is transferred from the ward supply in the hospital to the portable cylinder. If such a check and test had been carried out, the failure of the oxygen flow to the patient would immediately have been noticed and the situation rectified. ”
    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