On 22nd April 2020 I commenced an investigation into the death of Ivan Merryfield O'Neill aged 74 years. The investigation concluded at the end of the inquest on 20th November 2020. The conclusion of the inquest was a narrative conclusion: "On 21st April 2020 Mr Ivan Merryfield O'Neill attended hospital for dialysis. An accidental dislodgement ofa venous needle that takes blood under pressure to the dialysis machine occurred, which led to a significant bleed. Staffon the unit were unaware ofthe bleed, until an alarm from the dialysis machine sounded due to a drop in pressure. Mr O'Neill was.found to be unres onsive 6 having sustained a cardiac arrest due to hypovolemic shock, despite resuscitation attempts his life was pronounced extinct at 09.30 hours." The cause ofdeath was recorded as; 1a; Hypovolemic Shock 1 b; End-Stage Kidney Disease II; Polyneuropathy, Frailty and COVID 19 CIRCUMSTANCES OF THE DEATH During a regular dialysis appointment, Mr O'Neill bled to death when a venous needle became dislodged from the site ofhis arteriovenous fistula. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. ­
1. Mr O'Neill was known to be a restless patient during a dialysis session. This factor must have increased the risk of needle dislodgement.
2. Mr O'Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed.
3. Mr O'Neill was placed in a position which was outside of a clear line of sight from the nurses station.
4. 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. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th January 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr O'Neill and the CQC. I have also sent it to the Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 2

During a regular dialysis appointment, Mr O'Neill bled to death when a venous needle became dislodged from the site ofhis arteriovenous fistula.