PFD report

ROBERT ENTENMAN · Prevention of Future Deaths report

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Issued 3 Feb 2017•London Inner (South)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
5

Named on the report

Responses found
4

Of 5 recipients

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Delays in communicating suction catheter difficulties to doctors
  2. Delays in identifying and replacing blocked endotracheal tubes
    Part of recurring concern: Unsafe endotracheal tube management
  3. Failure to monitor humidifier operation and temperature
    Part of recurring concern: Unreliable oxygen humidifier safety controls
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Revise the Cardiac Arrest Record Checklist to prompt capnography and DOPES.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  2. Action

    Deliver ongoing advanced airway, simulation, mock-arrest and blocked-tube training for intensive care staff.

    Stated by HCA Healthcare UK and London Bridge HospitalStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  3. Action

    Use the Cardiac Arrest Record Checklist during arrests and audit and review post-arrest debrief records.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

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

    Stated by HCA Healthcare UK and London Bridge HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unsafe endotracheal tube management.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable oxygen humidifier safety controls.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 action was interpreted

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

PFD Monitor interpretation

Investigate the nursing-care concerns in accordance with statutory functions.

Verbatim wording from the response

“We are aware of the particular issues raised about the registered nurse who reviewed Mr Entenman in the time leading up to his death. We are currently investigating this matter and are considering the concerns in accordance with our statutory functions.”

Source location

2017-0011-Response-by-NMC
Page 1 · 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

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

The completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.

Verbatim wording from the response

“The CQC requested a final copy of the RCA document as part of the inspection process in 2016, and received this on 28 October 2016. The document had been completed on 30 October 2015. It set out the background to the incident, the possible causes and a proposed action plan to prevent the re-occurrence of similar incidents. The CQC was satisfied that the actions set out in the RCA would be sufficient to mitigate the risk of re-occurrence and, further, that those actions had been carried out.”

Source location

2017-0011-Response-by-Care-Quality-Commission
Page 2 · response
Published 19 February 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Review clinical skills periodically for Consultant Anaesthetists and provide recurring Consultant Intensivist supervision for CCRMOs.

    Stated by HCA Healthcare UK and London Bridge HospitalStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  2. 2

    Use a picture-based intubation checklist for all critically ill patient intubations.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  3. 3

    Introduce Human Factors Training into the curriculum for staff at all levels and record attendance in the Learning Management System.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  4. 4

    Maintain staff resuscitation qualifications and use the Learning Management System to flag revalidation requirements and restrict outdated key-role practice.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  5. 5

    Introduce an emergency induction checklist across HCA operations.

    Stated by HCA Healthcare UK and London Bridge HospitalStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  6. 6

    Offer RMOs rotational operating-theatre work with Consultant Anaesthetist airway-skills input.

    Stated by HCA Healthcare UK and London Bridge HospitalStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  7. 7

    Implement a five-step Airway Management Process using RAG airway scoring, bespoke plans, bedside signs and documented handover.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  8. 8

    Conduct twice-daily resuscitation-team safety briefings to identify high-risk airways, allocate arrest roles and document team assignments.

    Stated by HCA Healthcare UK and London Bridge HospitalStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  9. 9

    Provide continuing reflective practice for medical and nursing staff.

    Stated by HCA Healthcare UK and London Bridge HospitalStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  10. 10

    Continue monitoring hospital care through engagement meetings, notifications, patient and whistleblower information, and discuss the hospital’s response at the scheduled April 2017 meeting.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A single unexpected death with a provider RCA and ongoing Coroner investigation would not necessarily warrant an unannounced inspection absent related concerns.

    Stated by Care Quality CommissionNo action considered necessaryThe respondent said that no further action was needed.

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 clinical skills periodically for Consultant Anaesthetists and provide recurring Consultant Intensivist supervision for CCRMOs.

Verbatim wording from the response

“j. Consultant Anaesthetists will be undertaking a periodic review of clinical skills of, and Consultant Intensivists will meet on a similar basis with, the CCRMOs for clinical supervision.”

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 a picture-based intubation checklist for all critically ill patient intubations.

Verbatim wording from the response

“a. A picture intubation checklist has been developed and is used in all intubations of critically ill patients.”

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

Introduce Human Factors Training into the curriculum for staff at all levels and record attendance in the Learning Management System.

Verbatim wording from the response

“b. Accordingly, in July 2015, LBH introduced Human Factors Training as part of the curriculum to improve and develop situational awareness and which is open to all levels of staff to attend. Records of attendance are maintained in LMS (see A.2.2.b. above).”

Source location

2017-0011-Response-by-London-Bridge-Hospital
Page 7 · 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

Maintain staff resuscitation qualifications and use the Learning Management System to flag revalidation requirements and restrict outdated key-role practice.

Verbatim wording from the response

“b. The HCA Learning Academy, which is responsible for delivering education relevant to clinical processes, knowledge and skills to all HCA facilities, oversees the Learning Management System (“LMS”). LMS is a software system facilitating on-line access from home or work to undertake, complete and store training courses, as well as accommodate book- and classroom-based training for all staff. All data can be updated and stored and LMS provides a robust system for monitoring training records.”

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

Introduce an emergency induction checklist across HCA operations.

Verbatim wording from the response

“b. An emergency induction checklist is being introduced. This has been agreed by HCA’s Critical Care Delivery Group for implementation across all of HCA’s operations.”

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

Offer RMOs rotational operating-theatre work with Consultant Anaesthetist airway-skills input.

Verbatim wording from the response

“l. LBH will offer its RMOs rotational work in the operating theatres. This is for RMOs to receive regular updates and input from Consultant Anaesthetists on airway skills.”

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

Implement a five-step Airway Management Process using RAG airway scoring, bespoke plans, bedside signs and documented handover.

Verbatim wording from the response

“B.1. A new Airway Management Process has been introduced:”

Source location

2017-0011-Response-by-London-Bridge-Hospital
Page 5 · 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

Conduct twice-daily resuscitation-team safety briefings to identify high-risk airways, allocate arrest roles and document team assignments.

Verbatim wording from the response

“B.2. LBH Resuscitation Team: Safety Briefing Handover”

Source location

2017-0011-Response-by-London-Bridge-Hospital
Page 5 · 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

Provide continuing reflective practice for medical and nursing staff.

Verbatim wording from the response

“h. Reflective practice for medical and nursing staff continues to be facilitated.”

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

Continue monitoring hospital care through engagement meetings, notifications, patient and whistleblower information, and discuss the hospital’s response at the scheduled April 2017 meeting.

Verbatim wording from the response

“Following its inspection of the Hospital, the CQC continues to monitor the care provided through regular engagement meetings, notifications from the Hospital, information from patients and whistleblowers. The next engagement meeting is due to take place in April 2017. At that meeting, inspectors will discuss the Hospital’s response to the Coroner and any additional actions it has assured the Coroner that it will take.”

Source location

2017-0011-Response-by-Care-Quality-Commission
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

A single unexpected death with a provider RCA and ongoing Coroner investigation would not necessarily warrant an unannounced inspection absent related concerns.

Verbatim wording from the response

“CQC inspectors monitor all enquiries and notifications relating to individual providers, including statutory notifications, complaints or concerns from members of the public and whistleblowing concerns. The decision to undertake unannounced, focused inspections is informed by, but not dictated by such information. A single unexpected death, where the provider followed its duty in informing the CQC, was undertaking an RCA and there was a Coroner’s investigation ongoing would not necessarily trigger an unannounced inspection, unless in association with other related concerns. Such incidents are, however, likely to be discussed at engagement meetings between CQC inspectors and the provider.”

Source location

2017-0011-Response-by-Care-Quality-Commission
Page 2 · response
Published 19 February 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026