Recurring concern

Unsafe updating of clinical policies and guidance

First to latest report 23 Oct 2013 — 24 Oct 2025

Reports that mention this concern
21
Times this concern has been raised
26
Stated actions linked to this concern
31

What this concern includes

Includes failures in the dedicated clinical-policy and guidance-updating process, including identifying the need for revision, resolving ambiguity, incorporating external guidance, approving changes, communicating them and implementing associated safety actions.

What is not included
  • Excludes generic staff training, communication, documentation or governance deficiencies unless they directly concern updating or implementing clinical policies and guidance.
  • Excludes operational protocol changes that are not clinical policies or guidance, including non-clinical procedures and local operational instructions.
  • Excludes failures to follow an otherwise current and clear policy or guidance when no deficiency in updating, revising or implementing the policy itself is identified.
  • Excludes deficiencies in the substantive clinical care, equipment or staffing arrangements where no clinical-policy or guidance-updating failure is asserted.

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Liverpool

    AI-generated summary

    Isabella Hope HILL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Isabella Hope HILL was born prematurely at 26 weeks and died on 17 July 2013, aged 7 days, after complications associated with an umbilical venous catheter. Total Parenteral Nutrition fluid entered her abdomen after the catheter migrated, contributing to circulatory collapse, cardiac injury and subsequent cardiac arrest. The principal concern was that the Trust’s guidelines were not followed because an x-ray to confirm the catheter’s position was not performed when it should have been, raising concern about future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequacy of UVC guidelines

    Wider context from the report

    “As can be seen from the above Narrative, the facts of this case involved the use of Central Venous Catheterisation using an Umbilical Venous Catheter [UVC]. Whilst there can be complications of UVC insertion including mal-positioning and line migration, an x-ray is required to confirm clinically the position of a UVC [which can commonly be mal-positioned despite use of optimal operation technique]. The evidence heard confirmed the Trust's own guidelines were not followed in this case in that such an x-ray was not performed at a point during Isabella's treatment when it ought to have been, and the Trust's review confirms that this not being done amounted to sub-optimal standard. The Trust's document recommends a review of the UVC guidelines including a literature search of the UVC guidelines and discussions with senior colleagues at the other units in the practise, and of education and training around UVC guidelines. Having concluded this inquest, and whilst I acknowledge that the Trust have indicated that changes have already been instigated, I now write to the Trust to confirm that in my view the Trust should take action because issues surrounding the UVC guidelines – particularly in the absence of any national guidelines – gives rise to a concern of deaths in the future. I would therefore be obliged if the Trust would write to me in due course to confirm the outcome of their review once completed, setting out what is proposed in terms of changes to be made, and to explain what steps the Trust proposes to take to encourage medical staff to follow the guidelines. Perhaps the Trust would send me a copy of the full review document for my consideration once completed. ”

    Source location

    Isabella Hope HILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise and relaunch the neonatal UVC guideline requiring urgent catheter-tip assessment after unexpected deterioration.

    Verbatim wording from the response

    “b) The neonatal guideline in respect of UVCs was revised immediately and now includes the following statement: ‘Any sudden or unexpected deterioration in a baby with a central venous catheter in-situ should always prompt an urgent assessment of the position of the catheter tip. Serious complications such as pericardial effusion/cardiac tamponade or infusion of fluid into the pleural or peritoneal cavities should be excluded by x-ray or ultrasound’. The revised guideline was re-launched with the new cohort of junior medical trainees who commenced their placement in August 2013.”

    Source location

    2013-0281-Response-by-Liverpool-Womens-NHS
    Page 3 · response
    Published 23 October 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Extend the UVC guideline to address potential consequences of using a catheter in a non-optimal position.

    Verbatim wording from the response

    “c) Further guideline work is planned to include the potential consequences of using a central venous catheter that is not in an optimal position.”

    Source location

    2013-0281-Response-by-Liverpool-Womens-NHS
    Page 3 · response
    Published 23 October 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026