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.
Regulation 28: Prevention of Future Deaths report – Mitica Marin
https://www.judiciary.uk/wp-content/uploads/2020/03/Mitica-Marin-2020-0066-1.pdf
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