Recurring concern

Unsafe management of external ventricular drains

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First reported 30 Nov 2023•Latest report 20 Oct 2025

Definition

What this concern includes

Includes failures in controls dedicated to external ventricular-drain management, including drainage assessment, escalation when drainage stops or changes, relevant clinical guidance, staff training and competence assurance, equipment-use procedures, monitoring and specialist response.

Not included

Excludes nasogastric, urinary, chest and other non-ventricular drainage systems unless the assertion explicitly concerns external ventricular-drain management.
Excludes generic clinical training, staffing, documentation or escalation deficiencies that are not directly tied to external ventricular drains.
Excludes failures occurring after an external ventricular-drain concern has been reliably recognised and escalated, where the remaining issue is unrelated treatment or outcome.
Excludes general hydrocephalus, neurosurgical or intensive-care deficiencies without a specific external ventricular-drain control failure.

Reports: 2
Individual concerns: 4
Date range: 2023–2025
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England1

The Society Of British Neurological Surgeons1

University Hospitals Birmingham NHS Foundation Trust1

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.

20 Oct2025
Birmingham and Solihull
Concerns raised2
1. Failure to ensure mandatory adequate training for clinical staff using automated CSF drainage equipment
2. Failure to embed sustainable ongoing training for current and future staff using automated CSF drainage equipment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Train all relevant medical and nursing staff to use the Liquoguard system.
  Stated by University Hospitals Birmingham NHS Foundation TrustStatus at response
2. Action
  Establish a nine-person core-trainer group to deliver ongoing Liquoguard training, including for rotating and new staff.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
3. Action
  Make Liquoguard training a mandatory core competency for all new cardiac critical-care staff.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
1. Action
  Develop enhanced specialist training for cardiac critical-care nursing staff.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The current trained staff cohort is sufficient to ensure appropriately trained personnel are present whenever automated CSF drains are used.
  Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

John Christopher RUST · 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

John Christopher RUST underwent elective thoracic aortic replacement surgery and subsequently suffered uncontrolled cerebrospinal fluid loss after his drain became disconnected, causing a catastrophic and unsurvivable brain injury. He died on 29 March 2025. The principal concern was that staff training on automated CSF drainage systems was not mandatory or embedded sustainably, creating a risk of 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
Failure to ensure mandatory adequate training for clinical staff using automated CSF drainage equipment
Wider context from the report
“1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that "All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use..." 2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned. 3. However, the evidence of ████████ (author of the PSII report and consultant neurosurgeon) indicated it was his view that the training should be mandatory, and that consideration must be given to ensuring this was rolled out in a "sustainable" way to staff - both current and future - as opposed to a "knee-jerk reaction" where training is only given to a limited number of staff following an incident. 4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of "knee-jerk reaction" that ████████ was fearful of. 5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment. ”
Source location
John Christopher RUST · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to embed sustainable ongoing training for current and future staff using automated CSF drainage equipment
Wider context from the report
“1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that "All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use..." 2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned. 3. However, the evidence of ████████ (author of the PSII report and consultant neurosurgeon) indicated it was his view that the training should be mandatory, and that consideration must be given to ensuring this was rolled out in a "sustainable" way to staff - both current and future - as opposed to a "knee-jerk reaction" where training is only given to a limited number of staff following an incident. 4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of "knee-jerk reaction" that ████████ was fearful of. 5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment. ”
Source location
John Christopher RUST · 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
Train all relevant medical and nursing staff to use the Liquoguard system.

Verbatim wording from the response
“2. To date, 91 out of 122 (75%) of relevant staff have completed training on the Liquoguard system, including both medical and nursing staff.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 1 · response
Published 23 October 2025
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
Establish a nine-person core-trainer group to deliver ongoing Liquoguard training, including for rotating and new staff.

Verbatim wording from the response
“5. There are currently nine core trainers, comprising senior educators, Band 7 nurses, and Advanced Critical Care Practitioners, ensuring sustainability of training delivery including for new staff rotating into the service.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 1 · response
Published 23 October 2025
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
Make Liquoguard training a mandatory core competency for all new cardiac critical-care staff.

Verbatim wording from the response
“8. Training in the use of the Liquoguard system is now a core competency within the cardiac critical care unit and is mandatory for all new staff.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 23 October 2025
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
Develop enhanced specialist training for cardiac critical-care nursing staff.

Verbatim wording from the response
“4. Enhanced training has been developed for nursing staff who choose to specialise further in cardiac critical care; these individuals will act as core trainers for new staff.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 1 · response
Published 23 October 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The current trained staff cohort is sufficient to ensure appropriately trained personnel are present whenever automated CSF drains are used.

Verbatim wording from the response
“6. The cohort of trained staff is now sufficient to ensure that whenever these devices are used (approximately 10–12 times per year), appropriately trained personnel are present.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 1 · response
Published 23 October 2025
Open published response
30 Nov2023
Liverpool and the Wirral
Concerns raised2
1. Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate
2. Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Engage the Society of British Neurological Surgeons and NHS nurse specialists to develop an action plan and national guideline for external ventricular drain management.
  Stated by NHS EnglandStated planned
2. Action
  Obtain permission to share the Plymouth EVD management SOP with clinical leads on request.
  Stated by The Society Of British Neurological SurgeonsStated completed
Respondent positions 2
1. Position
  Existing local policies, educational materials and professional guidance address EVD care, while locally relevant policies remain appropriate for individual neurosurgical units.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  Individual Trusts are responsible for reviewing or developing local EVD standard operating procedures where necessary.
  Stated by The Society Of British Neurological SurgeonsRedirects responsibility
AI-generated summary

Katherine Sarah FLYNN · 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

Katherine Sarah Flynn, aged 34, underwent surgery for a malignant brain tumour and subsequently became dependent on an external ventricular drain. She died on 6 March 2022 after the drain stopped draining, hydrocephalus developed, and the drain was found to have dislodged. Concerns included failures to escalate reduced drainage and leakage to the medical team, and unclear guidance on escalation when a drain stopped draining but continued to oscillate.

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
Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate
Wider context from the report
“The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating. Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue. This is a risk which needs to be highlighted at a national level. ”
Source location
Katherine Sarah FLYNN · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues
Wider context from the report
“The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating. Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue. This is a risk which needs to be highlighted at a national level. ”
Source location
Katherine Sarah FLYNN · Prevention of Future Deaths report
Page 3 · 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
Engage the Society of British Neurological Surgeons and NHS nurse specialists to develop an action plan and national guideline for external ventricular drain management.

Verbatim wording from the response
“It is proposed that the Society of British Neurological Surgeons (SBNS) co-lead with NHS Nurse Specialists to develop an action plan and national guideline for EVD management. A short life Working Group (comprising both Surgeons and Specialist Nurses) should be considered as the way forward with input from NHS England’s National Patient Safety Team. The Patient Safety Team plans to reach out to the SBNS, who we note that you also sent your Report to.”

Source location
Response from NHS England
Page 2 · response
Published 6 December 2023
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
Obtain permission to share the Plymouth EVD management SOP with clinical leads on request.

Verbatim wording from the response
“Following the Coroner’s Report we ask you to review any SOP, or develop a SOP for your unit where necessary. Colleagues in Plymouth developed an SOP for the management of EVDs in Intensive Care. While this Regulation 28 will initiate review I have obtained permission from the authors for this to be shared with the Clinical Leads on request (to Suzanne).”

Source location
Response from Society of British Neurological Surgeons
Page 1 · response
Published 6 December 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing local policies, educational materials and professional guidance address EVD care, while locally relevant policies remain appropriate for individual neurosurgical units.

Verbatim wording from the response
“While there is currently no NHS-wide national policy available regarding nursing care of patients with EVDs, local policies (examples of which are included in the footnote below¹) and educational material regarding best practice are readily available. There is also national nursing guidance available from the British Association of Neuroscience Nurses regarding Cerebrospinal Fluid (CSF) Management. Leading Clinical Neurosurgery colleagues have also reviewed your Report and advised that every neurosurgical unit will have their own work skill mix and resources and be expected to develop locally relevant policies that would be valuable, relevant and safe. We note that in Katherine’s case, local policy was unfortunately not followed.”

Source location
Response from NHS England
Page 1 · response
Published 6 December 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Individual Trusts are responsible for reviewing or developing local EVD standard operating procedures where necessary.

Verbatim wording from the response
“Following the Coroner’s Report we ask you to review any SOP, or develop a SOP for your unit where necessary. Colleagues in Plymouth developed an SOP for the management of EVDs in Intensive Care. While this Regulation 28 will initiate review I have obtained permission from the authors for this to be shared with the Clinical Leads on request (to Suzanne).”

Source location
Response from Society of British Neurological Surgeons
Page 1 · response
Published 6 December 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure mandatory adequate training for clinical staff using automated CSF drainage equipment

Failure to embed sustainable ongoing training for current and future staff using automated CSF drainage equipment

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.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate

Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 4

Respondent positions 1

Actions described in response 2

Respondent positions 2