Ivan O'Neill

1. 1. needle dislodgement during dialysis

   “Mr [name redacted] was known to be a restless patient during a dialysis session. This factor must have increased the risk of needle dislodgement.”

2. 2. rapid loss of consciousness after bleed

   “Mr [name redacted] was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed.”

3. 3. patient out of nurses' line of sight

   “Mr [name redacted] was placed in a position which was outside of a clear line of sight from the nurses station.”

4. 4. insufficient alarm sensitivity for bleed detection

   “The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 - 2000 mls of blood had already been lost.”

No published response was found on judiciary.uk.