Recurring concern

Unsafe patient cannulation

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First reported 26 Feb 2014•Latest report 14 Nov 2023

Definition

What this concern includes

Includes failures of dedicated patient cannulation or vascular-access controls, including appropriate insertion, replacement, procedural requirements, clinical guidance, policy alignment and staff adherence, where the failure concerns safe cannulation itself.

Not included

Excludes generic clinical-procedure, staffing, training or documentation deficiencies that are not specifically tied to patient cannulation or vascular access.
Excludes failures involving administration, monitoring or treatment after vascular access has been safely established, unless the assertion directly concerns the cannulation or access procedure.
Excludes unrelated equipment or emergency-response failures, including incorrect defibrillator use, where no cannulation or vascular-access control is identified.
Excludes non-patient vascular or non-clinical access processes.

Reports: 4
Individual concerns: 6
Date range: 2014–2023
Stated actions: 4

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.

Department of Health and Social Care2

Academy of Medical Royal Colleges1

Association Of Anaesthetists (Great Britain & Ireland)1

British Association of Perinatal Medicine1

National Infusion and Vascular Access Society1

National Institute for Health and Care Excellence1

NHS England1

Royal College of Anaesthetists1

Royal Sussex County Hospital1

University Hospitals Sussex 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.

14 Nov2023
West Yorkshire (Western)
Concerns raised1
1. 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 3
1. 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 progress
2. 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 planned
3. Action
  Publish guidance recommending ultrasound locating devices for central venous catheter placement.
  Stated by National Institute for Health and Care ExcellenceStated completed
Respondent positions 3
1. 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 sufficient
1. 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 sufficient
2. 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 necessary
AI-generated summary

Maxwell Frame · 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

Maxwell Frame presented with sepsis caused by a pelvic abscess and bowel obstruction and underwent emergency surgery. A central venous catheter was incorrectly inserted into an artery and was later removed; clot dislodged during removal, causing strokes, after which he received palliative care and died. The report identified concern about the absence of a single national policy for central venous catheter placement.

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
Absence of a national policy on the placement of central venous catheters
Wider context from the report
“Absence of a national policy on the placement of CVC’s Over the course of the inquest hearing, oral evidence was provided by several anaesthetic/ ICU doctors ranging from experienced consultants, specialty Dr’s and a Core Trainee 2 all of whom had experience to varying degrees of placing CVC’s. These Dr’s had worked in several hospitals predominantly across the Midlands and North of England. The Trust had a policy entitled Central Venous Access Device which identified the steps that I have identified earlier should have taken place but were not. I was advised by the Dr’s who gave evidence that there was no single standard policy that they had encountered nationally for the placement of CVC’s. The Trust in this case following their internal investigation of Mr Frame’s case had felt it necessary to revise their policy. Further, I was advised by some of the Dr’s who gave evidence that they felt a national policy regarding the placement of CVC’s would be beneficial. ”
Source location
Maxwell Frame · 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
Update Safe Vascular Access guidance to include more explicit recommendations for checking central venous catheter placement.

Verbatim wording from the response
“In 2016, the Association of Anaesthetists published the guidance “Safe Vascular Access”¹, which was endorsed by the Royal College of Anaesthetists. Although this guidance does not contain a list of explicit recommendations for placement, information relating to how placement should be checked is included. The guideline does state "All hospitals should have clear, specific policies for insertion and documentation of CVCs (type, insertion site and tip position), and education on complications and their management." The guidance is currently being updated and we will ensure that it has more explicit recommendations for checking placement.”

Source location
Response from Association of Anaesthetists Royal College of Anaesthetists Intensive Care
Page 1 · response
Published 21 November 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
Publish guidelines on real-time ultrasound guidance and recognition and management of inadvertent arterial puncture or cannulation.

Verbatim wording from the response
“NIVAS has not yet published any guidelines specifically concerning the use of real time ultrasound guidance for central venous catheter insertion or the identification and management of inadvertent arterial puncture or cannulation although this is planned for 2024. The recognition of arterial puncture is mentioned in two recent competency documents for tunnelled and totally implanted vascular access devices which are available for download by our membership.”

Source location
Response from National Infusion and Vascular Access Society
Page 1 · response
Published 21 November 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
Publish guidance recommending ultrasound locating devices for central venous catheter placement.

Verbatim wording from the response
“NICE published guidance recommending the use of ultrasound locating devices for placing central venous catheters [TA49] in 2002. This guidance did not make any recommendation for placement of CVCs into the subclavian vein as there was a lack of specific evidence for subclavian placement at the time of publication. Since this guidance was published, ultrasound use for placement of central lines has become applicable to all sites.”

Source location
Response from National Institute for Health and Care Excellence
Page 1 · response
Published 21 November 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
Further NICE guidance on central venous catheter placement is not considered necessary because existing national recommendations and standard requirements are sufficient.

Verbatim wording from the response
“I was saddened to read of the circumstances surrounding Maxwell’s death. However, on this occasion I do not consider that further NICE guidance in this area would add to existing national recommendations from relevant professional bodies and standard requirements, prevent the failure to use ultrasound or to undertake recommended checks in line placement.”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 21 November 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 national standards and guidance are sufficient to inform local standards for central venous catheter placement.

Verbatim wording from the response
“In preparing this response, Departmental officials have made enquiries with the Care Quality Commission (CQC) and the National Institute for Clinical Excellence (NICE). In their published response to your report, NICE cite existing guidance and national safety standards, including: national safety standards for invasive procedures, national CVC Insertion Safety Checklist, as well as guidance on safe vascular access (2016) which recommends the use of ultrasound locating devices for placing CVC’s. The Department understands the guidance on safe vascular access is currently being updated and is due to be published in 2024. These existing standards and guidance should be used to inform local standards developed at the Trust.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 21 November 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
No further departmental action is considered necessary because the treating clinician departed from existing national recommendations, guidelines and Trust policy.

Verbatim wording from the response
“I was deeply saddened to read the circumstances of Mr Frame’s death. The report has prompted careful reflection within my department, and from NICE and other stakeholders involved in the issuing of national clinical guidance as detailed in their responses. However, as you note in your report, the actions taken by the treating clinician departed from already existing national recommendations, NICE guidelines for administering this procedure and the Trusts own policy. I therefore do not consider there is any further action for the Department of Health and Social Care to take at this time.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 November 2023
Open published response
19 Nov2020
Surrey
Concerns raised3
1. Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance
2. Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance
3. Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs
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 1
1. Action
  Publish an evidence-based Framework for Practice on neonatal central venous catheter use to reduce complications and support early recognition of extravasation.
  Stated by British Association of Perinatal MedicineStated completed
Respondent positions 4
1. Position
  NICE considers no direct action necessary at present, while logging the concerns for consideration during the next NG154 update.
  Stated by National Institute for Health and Care ExcellenceNo action considered necessary
1. Position
  Education and training of healthcare professionals is assigned to relevant professional bodies, including the Royal Colleges, GMC and Health Education England.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
2. Position
  The suggested amendment requiring NHS Trusts to ensure clinician familiarity with the current BAPM Framework is unnecessary and cannot be guaranteed to prevent recurrence.
  Stated by British Association of Perinatal MedicineNo action considered necessary
3. Position
  The BAPM framework is considered sufficient to contain information on UVC insertion and associated risks, so NICE will not produce specific recommendations.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
AI-generated summary

Master Yo Li · 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

Yo Li was born extremely prematurely on 11 January 2019 and died on 15 January 2019 after an umbilical venous catheter was mal-positioned, resulting in total parenteral nutrition extravasation. Concerns included gaps in professional guidance about a risk factor for mal-positioned catheters, clinicians’ lack of familiarity with updated guidance, and the absence of NICE guidance or a requirement for NHS Trusts to follow the relevant guidance.

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
Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance
Wider context from the report
“2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue. ”
Source location
Master Yo Li · 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 NHS Trust requirements for clinicians to be familiar with BAPM guidance
Wider context from the report
“2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue. ”
Source location
Master Yo Li · 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
Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs
Wider context from the report
“1. The BAPM guidance on ‘Use of Central Venous Catheters in Neonates – A Framework for Practice’ does not identify a key risk factor for a mal-positioned UVC. Consideration ought to be given by BAPM to updating the guidance to include reference to this risk factor. ”
Source location
Master Yo Li · 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
Publish an evidence-based Framework for Practice on neonatal central venous catheter use to reduce complications and support early recognition of extravasation.

Verbatim wording from the response
“Among BAPM’s resources are a series of Frameworks for Practice (FfPs) which, following review of the literature, are written by multi-professional, voluntary working groups and published on our website after national consultation. Our FfPs are therefore evidence-based, consensus documents: specifically they are not guidelines, but as you note, guidance. This makes them highly suitable to inform local guidelines and protocols appropriate for individual neonatal units and/or networks. BAPM FfPs are reviewed regularly and updated if new evidence has become available.”

Source location
2020-0245-Response-from-BAPM-Redacted.pdf
Page 1 · response
Published 24 December 2020
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
NICE considers no direct action necessary at present, while logging the concerns for consideration during the next NG154 update.

Verbatim wording from the response
“While we do not consider that direct action is required from NICE at this time, the concerns you have raised have been logged for further consideration when guideline NG154 is next reviewed for update.”

Source location
2020-0245-Response-from-NICE-Redacted.pdf
Page 2 · response
Published 24 December 2020
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
Education and training of healthcare professionals is assigned to relevant professional bodies, including the Royal Colleges, GMC and Health Education England.

Verbatim wording from the response
“We consider this an issue of training and awareness. The responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England.”

Source location
2020-0245-Response-from-NICE-Redacted.pdf
Page 2 · response
Published 24 December 2020
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 suggested amendment requiring NHS Trusts to ensure clinician familiarity with the current BAPM Framework is unnecessary and cannot be guaranteed to prevent recurrence.

Verbatim wording from the response
“While we agree wholeheartedly with your recommendation that there should be a requirement on NHS Trusts to ensure that their clinicians are familiar with the current BAPM FfP for the use of Central Venous Catheters in Neonates, with the greatest of respect we contend that the suggested amendment is unnecessary and could not be guaranteed to prevent a recurrence of the incident described which led to the sad death of Master Yo Li.”

Source location
2020-0245-Response-from-BAPM-Redacted.pdf
Page 3 · response
Published 24 December 2020
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 BAPM framework is considered sufficient to contain information on UVC insertion and associated risks, so NICE will not produce specific recommendations.

Verbatim wording from the response
“We do not consider it appropriate for NICE to produce guideline recommendations specifically describing how to insert UVC lines.”

Source location
2020-0245-Response-from-NICE-Redacted.pdf
Page 2 · response
Published 24 December 2020
Open published response
15 Feb2016
Plymouth, Torbay and South Devon
Concerns raised1
1. Need for improvement in central venous line insertion processes
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.
Respondent positions 1
1. Position
  Mandating a higher number of line-insertion procedures would not prevent this complication.
  Stated by Faculty of Intensive Care MedicineDisputes the concern
AI-generated summary

Peter Charles Tye · 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

Peter Charles Tye was admitted to Derriford Hospital with pneumonia and respiratory failure, and a central venous line was mistakenly inserted into his carotid artery. He later deteriorated with gram-negative sepsis and died; concerns focused on improving the insertion and removal of central venous lines to reduce deaths from misplaced lines.

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
Need for improvement in central venous line insertion processes
Wider context from the report
“At an Inquest touching the death of Peter Charles Tye, I received evidence from ████████ that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines. Details have been shared with the Faculty of Intensive Care Medicine. In my view deaths might be reduced by the promulgation of this good practice. ”
Source location
Peter Charles Tye · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Mandating a higher number of line-insertion procedures would not prevent this complication.

Verbatim wording from the response
“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case. The spiral nature of our curriculum requires the trainee to demonstrate increasing levels of competence for this procedure resulting in a competence which would indicate that the trainee was capable of independent level practice. This is assessed by means of workplace based assessments, performed by consultant trainers who would also assess the trainee's knowledge of the indications for and complications of the procedure.”

Source location
Peter-Tye-Response
Page 1 · response
Published 15 February 2016
Open published response
26 Feb2014
Brighton and Hove
Concerns raised1
1. Failure to cannulate patients appropriately
This report raised 6 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.
AI-generated summary

Herta Edith Maria WOODS · 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

Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

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 cannulate patients appropriately
Wider context from the report
“(5) Failure to cannulate her appropriately. Her cannula had initially been inserted by the ambulance crew; this isued and needed to be replaced. The requirements concerning cannulation of patients are strict. They were not adhered to in Mrs. Wood's case. This should have been dealt with in A & E. ”
Source location
Herta Edith Maria WOODS · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Absence of a national policy on the placement of central venous catheters

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised3

Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance

Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance

Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Need for improvement in central venous line insertion processes

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

Concerns raised1

Failure to cannulate patients appropriately

Actions described in response 3

Respondent positions 3

Actions described in response 1

Respondent positions 4

Respondent positions 1