AINALIDIS Taylor

Contributing factors

• Congenital heart disease (Tetralogy of Fallot)
• Degradation of anaesthetic rebreathe bag rubber causing stickiness
• Failure to follow manufacturer's sterilisation instructions (autoclaving instead of sodium hydrochloride based sterilants)
• Failure to check equipment for defects before clinical use
• Lack of hospital system to monitor deterioration of reusable equipment

Coroner's recommendations

1. Establish a system to ensure that mechanical or life-supporting products with catastrophic failure potential are carefully evaluated for patient safety before introduction to ward areas
2. Ensure product information and training material is provided to all relevant staff and readily available with the product
3. Regularly and proactively seek updated product information from manufacturers
4. Conduct regular audits and checks of products for safety, suitability and compliance with original specifications
5. Ensure maintenance or cleaning processes comply with manufacturer specifications
6. Undertake regular, detailed documented audits of the systems
7. Involve the Hospital's Risk Management Group in the assessment process
8. Ensure adequate training on the use, maintenance and risk factors of mechanical or life-supporting products is provided to all relevant staff