A patient in the critical care unit of a hospital suffered brain damage and later died while nurses sat outside his room because the alarm volume was not turned up, an inquest heard.

Christopher Osland, 65, was admitted to Kent and Canterbury Hospital following a stroke on March 30 last year and suffered a cardiac arrest two days later.

But the alarm volume had been decreased to a point where nurses who were on a shift changeover could not hear his distress, the inquest heard.

Not only that, but the alerts at the hospital's nurses station to check on Mr Osland had been turned off a week before so they had no idea what was happening.

East Kent NHS trust has blamed the death on a lack of training around the new machine that monitored the system in his room.

After being admitted Mr Osland, of Cheriton, Folkestone, was moved to ITU where his condition was improving and was being taken off his ventilator for three hours at a time.

But on April 26, Mr Osland went into cardiac arrest. He did not regain consciousness and died on May 12 2021 after the withdrawal of clinical support.

In a narrative verdict at an inquest held before a jury, Mr Osland's cause of death was given as hypoxic ischaemic encephalopathy, meaning a brain injury caused by oxygen deprivation to the brain.

Assistant coroner Kate Thomas said: "The evidence at the inquest was that not all nurses knew that the sound level of alarms on room monitors could be reduced and so did not check alarm volume when coming on shift."

There was no evidence that once the alarms had been silenced, any steps had been taken to ensure the room monitor and central monitor were reconnected, the inquest was told.

Both units were working correctly, the assistant coroner found.

In a report to prevent future deaths sent to East Kent Hospitals University NHS Foundation Trust, the assistant coroner raised several concerns.

Ms Thomas said: "Nursing staff are unaware that the room monitor volume could be reduced to the point were it was not audible outside the room - as a result, the volume of the room alarm was not part of handover equipment checks.

"The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced.

"After silencing the OFF COMS alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor.

"No steps had been taken to respond to the OFF COMS notification on the central monitor screen which had persisted for the five days prior to the April 26.

"It is unclear as to when the OFF COMS disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland's arrest.

"It was unclear what steps nurses were supposed to take when confronted with an OFF COMS alert or screen notification.

"In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

The report to prevent future deaths were also forwarded to the Care Quality Commission, NHS England and Improvement, as well as Mr Osland's son and widow.

Sarah Shingler, Chief Nursing and Midwifery Officer at East Kent Hospitals, said: "Our thoughts are with the family and friends of Mr Osland and we are deeply sorry for the failings in his care.

"The coroner has acknowledged that we have made a number of changes to ensure this does not happen again, including improving training for staff, ensuring that handovers take place at a patient's bedside and equipment is checked regularly.

"We are responding to the coroner's report and will make any further changes that are needed."