Regulation 28: Prevention of Future Deaths report – Mitica Marin

Summary

Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. 

This is a coroner's report into the death of 35 year-old Mr Mitica Marin.

It was found that the defibrillator was set to manual mode, which  meant that staff were not automatically alerted to the fact that Mitica's heart had a shockable rhythm. This caused a delay to Mr Marin receiving CPR treatment.