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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
NHS England1
The Society Of British Neurological Surgeons1
University Hospitals Birmingham NHS Foundation Trust1
Executive non-departmental public body1
NHS trust1
Registered charity1
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
Birmingham and Solihull
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
Linked response
University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
University Hospitals Birmingham NHS Foundation Trust
Train all relevant medical and nursing staff to use the Liquoguard system.
University Hospitals Birmingham NHS Foundation Trust
Establish a nine-person core-trainer group to deliver ongoing Liquoguard training, including for rotating and new staff.
University Hospitals Birmingham NHS Foundation Trust
Make Liquoguard training a mandatory core competency for all new cardiac critical-care staff.
University Hospitals Birmingham NHS Foundation Trust
Develop enhanced specialist training for cardiac critical-care nursing staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
University Hospitals Birmingham NHS Foundation Trust
The current trained staff cohort is sufficient to ensure appropriately trained personnel are present whenever automated CSF drains are used.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Liverpool and the Wirral
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
Linked responses
NHS England
The Society Of British Neurological Surgeons
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
NHS England
Engage the Society of British Neurological Surgeons and NHS nurse specialists to develop an action plan and national guideline for external ventricular drain management.
The Society Of British Neurological Surgeons
Obtain permission to share the Plymouth EVD management SOP with clinical leads on request.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Existing local policies, educational materials and professional guidance address EVD care, while locally relevant policies remain appropriate for individual neurosurgical units.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
The Society Of British Neurological Surgeons
Individual Trusts are responsible for reviewing or developing local EVD standard operating procedures where necessary.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.