“Nursing staff are unaware that the room monitor volume could be reduced to the point…”
Dated 22 Feb 2022, from the coroner for North East Kent. 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
Deadline passedReplies were due by 19 Apr 2022. 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 dated22 Feb 2022
- Deadline19 Apr 2022
- Published on judiciary.uk28 Feb 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Kent Hospitals University NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1) Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room – as a result, the volume of the room alarm was not part of hand over equipment checks. 2) The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced 3) Af ter silencing the ‘OFF COMS’ alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor. 4) No steps had been taken to respond to the ‘OFF COMS’ notification on the central monitor screen which had persisted for the 5 days prior to the 26 th April 2021 5) Specifically in respect of points 3 & 4, it is unclear as to when the ‘OFF COMS’ disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland’s arrest. 6) It was unclear what steps nurses were supposed to take when confronted with an ‘OFF COMS’ alert or screen notification.
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, 2022-0060
- 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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