Mark Stephen Anthony Simon KUBIAK · Prevention of Future Deaths report

On 31/07/2018 I commenced an investigation into the death of Mark Stephen Anthony Simon KUBIAK aged 61. The investigation concluded at the end of the inquest on 11th March 2019. The narrative conclusion of the inquest was:

The deceased suffered from acute necrotising pancreatitis and was cared for in the department of critical care at Milton Keynes University Hospital. On the 25th July 2018 it was decided to transfer him to the John Radcliffe Hospital in Oxford for surgical intervention. He was transferred to a portable ventilator and the oxygen supply was not connected properly and the lack of ventilation was not recognised. He suffered a cardiac arrest and died at 12:34 on 25th July 2018.

The circumstances were that Mr Kubiak was being transferred from Critical Care at Milton Keynes Hospital to Intensive Care at the John Radcliffe Hospital. The Transfer network checklist was being followed but the checklist does not require the change of oxygen supply to be tested, or for a tug test to be carried out. When Mr Kubiak left the department the oxygen was not properly connected to the portable cylinder.

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.

The checklist needs to be reviewed and updated to include the test suggested.