Robert Ginn
30 Oct 2019 · Coroner ME Hassell · London Inner (North)
The coroner's concerns
1. failure to maintain adequate patient temperature
“The nurse (Hotel 12) who gave evidence at inquest said that Mr [name redacted] was cold when she got to him, but the LAS paramedic who arrived later was confident that he was still warm, and his temperature was recorded as 34.7°C.”
2. failure to check breathing
“Throughout the resuscitation attempt captured on BWC, no staff member checked Mr [name redacted] breathing.”
3. failure to confirm absence of breathing
“At inquest, one of the nurses said that she looked at Mr [name redacted] chest at the outset, but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing.”
4. failure to maintain oxygenation
“After the first two minutes of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr [name redacted].”
5. inadequate chest compressions
“Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal.”
6. failure to improve chest compression quality
“No attempt was made by either of the nurses to coach the prison Officer to improve the quality of chest compressions.”