“The apparent absence of or use of an upper alarm setting on a bedside oxygen meter”
Dated 15 Jan 2026, from the coroner for Shropshire, Telford and Wrekin. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 12 Mar 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated15 Jan 2026
- Deadline12 Mar 2026
- Published on judiciary.uk21 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Shrewsbury and Telford Hospital NHS TrustNamed in the report as “Shewsbury and Telford Hospital Trust” | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(1) The apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations as and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. (2) The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. (3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0022
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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