Christopher Williams
19 Mar 2014 · Coroner Alan Moore · Cheshire
The coroner's concerns
1. defibrillator failure
“The defibrillator machine did not work, even when the battery pack was changed”
2. lack of daily equipment checks
“The defibrillator had not been checked on 5 November, although there was a requirement for the equipment to be checked daily for serviceability by the nursing staff”
3. absence of double check system
“There was no 'cross-check' or 'double check' system in place”
4. missing death management policy
“There was no policy or protocol in place at the hospital for the management of sudden / unexpected deaths”
Responses
No published response was found on judiciary.uk.