“are that: (1) Three nurses cared for Mr Entenman between 12.00pm on 22 May 2015 and…”
Dated 3 Feb 2017, from the coroner for Inner South London. Sent to 5 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 31 Mar 2017. A reply may have been sent and not yet published.
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.
- Report dated3 Feb 2017
- Deadline31 Mar 2017
- Published on judiciary.uk19 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| London Bridge Hospital | Response publishedPublished on judiciary.uk in February 2017. |
| HCA Health Care UK | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 31 Mar 2017. A reply may have been sent and not yet published. |
| Fisher and Paykel | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 31 Mar 2017. A reply may have been sent and not yet published. |
| Nursing and Midwifery CouncilNamed in the report as “The Nursing Midwifery Council” | Response publishedPublished on judiciary.uk in February 2017. |
| Care Quality CommissionNamed in the report as “The Care Quality Commission” | Response publishedPublished on judiciary.uk in February 2017. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
are that: (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 at the handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier. (2) The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off. (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.
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, 2017-0011
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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