inforMED
DeathBTM

CURAPLEX

Received Feb 20, 2025 · Event occurred Jan 19, 2025

Report 1314417-2025-00006 · MDR key 21426527

Device

Generic name

Curaplex Bvm, Adult, Mask Size 5, Universal Connector, 7ft O2 Tubing

Manufacturer

Sunmed Ap, Ltd.

Model number

301-BVM1500

Catalog number

2442-BVM1500

Lot number

479693

Product problems

  • Incomplete or Missing Packaging
  • Incomplete or Missing Packaging

Patient

NA · Unknown

  • Low Oxygen Saturation
  • Low Oxygen Saturation

Narrative

Description of Event or Problem

ROULETTE CHEMICAL ENG CO, HAS REPORTED "EMS SERVICES WAS AT A CALL, NEEDED A BVM. 2 BAGS THEY RECEIVED DID NOT HAVE THE FACE MASK IN THE BAGS, DELAYING PATIENT CARE. DAWN CONFIRMED THERE WAS A DEATH INVOLVED AFTER THE PATIENT WAS BROUGHT TO THE HOSPITAL." AS THERE IS A REPORT OF TWO BAGS WITH SAME ISSUE, WE WILL SUBMITTING 2 MDR REPORTS TOR THIS INCIDENT. THE SECOND MDR RELATED TO THIS INCIDENT IS 1314417-2025-00007.

Additional Manufacturer Narrative

H6: 4756 (APPROPRIATE IMPACT TERM/CODE NOT AVAILABLE): RESUSCITATION BAG W/MASK. THE PRODUCT INVOLVED IN THE REPORT HAS NOT BEEN RETURNED. A REVIEW OF THE DEVICE HISTORY RECORD IS IN-PROGRESS. ALL INFORMATION REASONABLY KNOWN AS OF 20 FEB 2025 HAS BEEN INCLUDED IN THE HEALTH AUTHORITY REPORT. SHOULD ADDITIONAL INFORMATION BE OBTAINED A FOLLOW-UP HEALTH AUTHORITY REPORT WILL BE PROVIDED. THE INFORMATION PROVIDED BY AIRLIFE. REPRESENTS ALL OF THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT/REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO AIRLIFE. AIRLIFE HAS NO INDEPENDENT KNOWLEDGE OF THE EVENT REPORTED BUT IS RELAYING THE INFORMATION THAT WAS PROVIDED BY THE USER FACILITY WHERE THE INCIDENT OCCURRED. THIS PRODUCT INCIDENT IS DOCUMENTED IN THE AIRLIFE COMPLAINT DATABASE AND IS IDENTIFIED AS COMPLAINT: (B)(4). THIS INFORMATION IS SUBMITTED PURSUANT TO 21CFR803, IN COMPLIANCE WITH THE MEDICAL DEVICE REPORTING REQUIREMENT AND SHOULD NOT BE CONSIDERED TO BE AN ADMISSION THAT A AIRLIFE PRODUCT IS DEFECTIVE OR CAUSES SERIOUS INJURY.

Additional Manufacturer Narrative

H6: 4756 (APPROPRIATE IMPACT TERM/CODE NOT AVAILABLE): RESUSCITATION BAG W/MASK. THE PRODUCT INVOLVED IN THE REPORT HAS NOT BEEN RETURNED. A REVIEW OF THE DEVICE HISTORY RECORD IS IN-PROGRESS. ALL INFORMATION REASONABLY KNOWN AS OF 20 FEB 2025 HAS BEEN INCLUDED IN THE HEALTH AUTHORITY REPORT. SHOULD ADDITIONAL INFORMATION BE OBTAINED A FOLLOW-UP HEALTH AUTHORITY REPORT WILL BE PROVIDED. THE INFORMATION PROVIDED BY AIRLIFE. REPRESENTS ALL OF THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT/REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO AIRLIFE. AIRLIFE HAS NO INDEPENDENT KNOWLEDGE OF THE EVENT REPORTED BUT IS RELAYING THE INFORMATION THAT WAS PROVIDED BY THE USER FACILITY WHERE THE INCIDENT OCCURRED. THIS PRODUCT INCIDENT IS DOCUMENTED IN THE AIRLIFE COMPLAINT DATABASE AND IS IDENTIFIED AS COMPLAINT (B)(4). THIS INFORMATION IS SUBMITTED PURSUANT TO 21CFR803, IN COMPLIANCE WITH THE MEDICAL DEVICE REPORTING REQUIREMENT AND SHOULD NOT BE CONSIDERED TO BE AN ADMISSION THAT A AIRLIFE PRODUCT IS DEFECTIVE OR CAUSES SERIOUS INJURY. THE COMPLAINT OF "2 BAGS THEY RECEIVED DID NOT HAVE THE FACE MASK IN THE BAGS, DELAYING PATIENT CARE" REGARDING PART 2442-BVM1500 WAS NOT CONFIRMED. THE ROOT CAUSE WAS DETERMINED TO BE THAT THERE IS NO VISUAL AID OR WEIGHING SYSTEM TO DETERMINE IF ALL OF THE REQUIRED COMPONENTS ARE PRESENT IN THE FINISHED GOOD. A RISK ASSESSMENT WAS PERFORMED AND THE ULTIMATE RISK WAS DETERMINED TO BE HIGH WHICH DOES REQUIRE ESCALATION TO THE CAPA REVIEW BOARD. THERE HAVE BEEN 7 OTHER COMPLAINTS REGARDING THE SAME PART AND A SIMILAR ISSUE WITHIN THE 24 MONTHS PRECEDING THIS REPORTED EVENT. A RESOLUTION LETTER WAS SENT TO THE CUSTOMER. COMPLAINTS WILL CONTINUE TO BE MONITORED FOR POSSIBLE TRENDS.

Description of Event or Problem

(B)(6), HAS REPORTED "EMS SERVICES WAS AT A CALL, NEEDED A BVM. 2 BAGS THEY RECEIVED DID NOT HAVE THE FACE MASK IN THE BAGS, DELAYING PATIENT CARE. (B)(6) CONFIRMED THERE WAS A DEATH INVOLVED AFTER THE PATIENT WAS BROUGHT TO THE HOSPITAL." AS THERE IS A EPORT OF TWO BAGS WITH SAME ISSUE WE WILL SUBMITTING 2 MDR REPORTS TOR THIS INCIDENT. THE SECOND MDR RELATED TO THIS INCIDENT IS 1314417-2025-00007.