inforMED
DeathCAP

AIRWAY PRESSURE MONITOR

Received Feb 17, 2005 · Event occurred Nov 16, 2003

Report 2518422-2005-00012 · MDR key 573615

Device

Generic name

Monitor, Airway Pressure

Manufacturer

Respironics, Inc.

Model number

332259

Catalog number

332259

Lot number

NA

Product problems

  • Unknown (for use when the device problem is not known)

Patient

17 YR

  • Death
  • Respiratory Failure

Narrative

Description of Event or Problem

INFO WAS RECEIVED THAT A PT EXPIRED WHILE USING THE DEVICE. REPORT ALLEGED THAT THE PT'S FAMILY MEMBER WAS AWAKENED BY A CHANGE IN THE SOUND OF THE CONCOMITANT DEVICE AND THAT NO ALARM REPORTEDLY SOUNDED. THE REPORT ALLEGES THAT THE PT WAS DISCOVERED TO BE NOT BREATHING AND WAS LATER PRONOUNCED DEAD. DESPITE ATTEMPTS TO OBTAIN ADDITIONAL INFO, NONE HAS BEEN MADE AVAILABLE. ADDITIONAL PT HISTORY AND A COPY OF THE CORONER'S REPORT ARE UNK. THE EQUIPMENT AND ALARM SETTINGS AT THE TIME OF THE EVENT ARE UNK. AN EVAL OF THE UNIT HAS NOT BEEN PERFORMED AT THIS TIME AND EFFORTS TO OBTAIN THE EQUIPMENT HAVE BEEN UNSUCCESSFUL. IT IS UNK AT THIS TIME WHETHER A DEVICE FAILURE HAD ACTUALLY OCCURRED, AND WHETHER THERE WAS ANY ASSOCIATION BETWEEN THE USE OF THE DEVICE AND THE PT'S OUTCOME.

Remedial action

  • Other