First reported 15 Feb 2016•Latest report 12 Dec 2024
Definition
What this concern includes
Includes failures in the dedicated central venous catheter management process, including insertion, positioning, securement, capping, mobilisation, monitoring, maintenance, removal and related guidance or competence controls where these directly address central venous catheter safety.
Not included
Excludes generic vascular-access, staffing, training, documentation or communication deficiencies where central venous catheter management is not the identified unsafe condition.
Excludes manufacturing or product-design defects in catheter components unless the report also identifies a failure in the clinical management of the central venous catheter.
Excludes unrelated peripheral cannula, arterial-line, dialysis-line or other device concerns unless the assertion explicitly concerns the same central venous catheter management process.
Excludes clinical care after a central venous catheter has been safely managed when the remaining deficiency is unrelated to catheter safety.
Reports
9
Distinct published reports
Individual concerns
13
A report can raise multiple concerns
Date range
2016–2024
First to latest report issue date
Stated actions
35
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care5
Academy of Medical Royal Colleges1
Association Of Anaesthetists (Great Britain & Ireland)1
Aston Medical School1
Birmingham Medical School1
Bolton NHS Foundation Trust1
British Renal Society1
General Medical Council1
Mid and South Essex NHS Foundation Trust1
National Infusion and Vascular Access Society1
National Institute for Health and Care Excellence1
Northern Care Alliance NHS Foundation Trust1
Queen's Hospital, Romford1
Royal College of Anaesthetists1
Royal London Hospital1
Ministerial department5
NHS trust5
Health professional body2
Registered charity2
Executive non-departmental public body1
Health and care professional regulator1
Healthcare site1
Multi-service care provider1
University faculty or school1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Essex
Concerns raised1
Failure to promptly remove an unused Hickman catheter
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Report the delay in Hickman line removal retrospectively to identify issues and necessary preventive action.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Present the Hickman line case to the vascular governance team and reinforce timely removal and compliance with the central venous access policy.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Remind inpatient adult wards to access the central venous access policy and remove Hickman lines promptly.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Inner North London
Concerns raised1
Poor maintenance of PICC lines
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Audit line insertion and care across wards, provide feedback, and continue monitoring infection-control performance.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Provide line-care, CRBSI and Surgical ANTT education for nursing, medical, surgical and other relevant staff.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Improve nursing and ward-housekeeper staffing and retention to support line management and infection prevention.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Operate multidisciplinary line-infection governance through the Surgical IPC and Harm Free Care Forum and monitor its infection-reduction action plan.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Implement ANTT monitoring and training across wards, with audits and a target of at least 85% compliance.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Action
Update IPC statutory and mandatory training to align with revised national standards.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
Action
Rewrite the ANTT policy with microbiology and IPC teams and embed it in training and competency requirements aligned with national guidelines.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A comprehensive Serious Incident investigation was not considered necessary because the clinical timeline did not warrant it; events were investigated locally.
Stated by Barts Health NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
West Yorkshire (Western)
Concerns raised1
Absence of a national policy on the placement of central venous catheters
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Update Safe Vascular Access guidance to include more explicit recommendations for checking central venous catheter placement.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists and The Intensive Care SocietyStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2023.
Action
Publish guidelines on real-time ultrasound guidance and recognition and management of inadvertent arterial puncture or cannulation.
Stated by NIVAS (National Infusion and Vascular Access SocietyStated plannedThe respondent said that this action was planned when they made their response on 21 November 2023.
Action
Publish guidance recommending ultrasound locating devices for central venous catheter placement.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Further NICE guidance on central venous catheter placement is not considered necessary because existing national recommendations and standard requirements are sufficient.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing national standards and guidance are sufficient to inform local standards for central venous catheter placement.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No further departmental action is considered necessary because the treating clinician departed from existing national recommendations, guidelines and Trust policy.
Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.
Leicester City and South Leicestershire
Concerns raised1
Lack of policies and procedures preventing failure to cap patent central venous catheter lines during patient mobilisation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Update and publish dialysis guidance addressing safe haemodialysis catheter handling and air-embolism risks.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
South Yorkshire (Western)
Concerns raised1
Failure to inform parents about plans to review, reassess and remove a central line
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Amend umbilical-line documentation to clarify target positions and require informing parents about suboptimal catheter position.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Birmingham and Solihull
Concerns raised3
Lack of doctors' understanding of taking bloods from central lines and associated risks
Failure to formally assess junior doctors' competence to take bloods from central lines
Lack of a standard written procedure for taking bloods from central lines
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Action
Cascade learning from the report to Postgraduate Deans and Foundation Schools, reinforcing competency, training and supervision requirements.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Provide Foundation doctors theoretical central-line education, including simulation of air embolism during blood sampling.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Introduce central-line procedural-risk teaching into Trust induction and medical-student and Foundation-doctor education.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Send Trust-wide precautions on central venous catheters and air-embolism risks to doctors.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 April 2021.
Action
Write a new pictorial guideline emphasising that central-line caps and clamps must not be open simultaneously.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Publish a central-line Learning Alert and send intermittent reminders on safe sampling processes to relevant doctors and nurses.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Write to UK Postgraduate Deans requesting protected-time induction, best practice and reinforcement of Foundation Professional Capability 18.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Reinforce to Trust trainees that central-line procedures are restricted to appropriately trained specialist settings and that Foundation doctors must not perform them.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Liaise with Health Education England to determine competency-assignment and supervision arrangements for clinical skills.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Forward clinical-skills competence summaries between rotations and require supervisors to check competency before assigning procedures.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Require documented competency and prohibit unsupervised procedures until trainees are signed off as competent.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2021.
Action
Continue working with employers, Health Education England and medical schools to monitor actions and ensure sustainable training-environment safety changes.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
National standard operating procedures for central-line blood sampling are matters for national service and education providers such as Health Education England and NHS England.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
At the Trust, blood sampling from central venous catheters is assigned to competent nursing staff, outreach teams or medical registrars rather than Foundation doctors.
Stated by Sandwell and West Birmingham Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Central-line blood sampling should not be required of all Foundation doctors because it is specialist work requiring specific authorisation, training and direct supervision.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised2
Lack of national guidelines for central venous catheter removal
Failure to provide constant visual observation after central venous catheter removal
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Issue an advisory alert to NHS England highlighting haemorrhage-prevention precautions and post-procedure observation and supervision.
Stated by Caroline Dinenage MPStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Raise awareness of CVC-removal haemorrhage risks with the UK Renal Association and British Renal Society.
Stated by Sir David DaltonStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Review and develop Trust-wide CVC documentation, guidance, checklists and electronic patient-record materials through a multidisciplinary task group.
Stated by Sir David DaltonStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2018.
Action
Obtain Trust approval and disseminate the revised CVC policy.
Stated by Sir David DaltonStated plannedThe respondent said that this action was planned when they made their response on 26 September 2018.
Action
Provide a haemodialysis central-line removal quick-reference guide on the intranet.
Stated by Sir David DaltonStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Review the central reference guide and link it with the haemodialysis central-line removal quick-reference guide.
Stated by Sir David DaltonStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2018.
Action
Include femoral-versus-neck CVC removal requirements in Trust policy and protocols, and provide related training.
Stated by Sir David DaltonStated plannedThe respondent said that this action was planned when they made their response on 26 September 2018.
Action
Require pre-removal CVC bleeding-risk assessment and senior medical review of observation arrangements for patients identified as high risk.
Stated by Sir David DaltonStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Universal one-hour direct observation after CVC removal would not assure prevention of haemorrhage and could create risks to other patients.
Stated by Sir David DaltonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Lack of written discharge guidance for monitoring, cleaning and flushing Hickman or central lines
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Plymouth, Torbay and South Devon
Concerns raised2
Need for improvement in central venous line insertion processes
Need for improvement in central venous line removal processes
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mandating a higher number of line-insertion procedures would not prevent this complication.
Stated by Faculty of Intensive Care MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures in the dedicated central venous catheter management process, including insertion, positioning, securement, capping, mobilisation, monitoring, maintenance, removal and related guidance or competence controls where these directly address central venous catheter safety.
