8 Oct 2025 William King · Prevention of Future Deaths report Milton Keynes
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Concerns raised 4 Inadequate explanation of NG tube risks and necessity to patients View source Failure to document consent discussions about NG tube treatment View source Failure to implement consent policy in practice View source Absence of clear responsibility for explaining NG tube necessity View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
William King · 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
William King died at Milton Keynes University Hospital on 26 January 2025 following an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The principal concerns were inadequate explanation and documentation of the risks and necessity of a nasogastric tube, failure to implement the relevant consent policy, and unclear responsibility for ensuring this aspect of care was addressed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Inadequate explanation of NG tube risks and necessity to patients
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage . There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Failure to document consent discussions about NG tube treatment
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor . Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case . The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Failure to implement consent policy in practice
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice , suggesting a gap between policy and practice that may affect other patients . The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content .
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care.
I conclude that, since the policy was not followed despite being in place , there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Absence of clear responsibility for explaining NG tube necessity
Wider context from the report “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed
ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary.
iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content.
iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy . The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care .
I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring.
These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.
” Open source report
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” Open source report
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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 Share learning from Mrs Marking’s death with members and publish a best-practice statement on RSI.
Verbatim wording from the response “The most important step to reduce the risks associated with RSI, as recommended by NAP4, is to undertake an individualised risk assessment and act on it. The NAP4 report⁷ states “All patients should have their risk of aspiration assessed and recorded before anaesthesia. The airway management strategy should be consistent with the identified risk of aspiration.” Furthermore, NAP7 report⁸ recommends “Anaesthetists should treat cases of acute abdomen as high risk for aspiration, assess the extent of that risk and plan airway management accordingly. Each airway manager should decide which elements of RSI they wish to use and be prepared to justify their use or omission.” We reinforce our support for these statements and will share the learning from Mrs Marking’s death with our members. As part of this we will publish a best practice statement on RSI.” Source location Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Open published response
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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 Limited evidence means fully evidenced national guidelines for rapid sequence induction are unlikely to be produced.
Verbatim wording from the response “It is worth stating from the outset that the topic of rapid sequence induction (RSI) is controversial. By its emergency nature it is difficult to study scientifically and robust evidence supporting or refuting many of its components is simply lacking. Given the challenges of designing studies to provide stronger evidence for or against its use, it is unlikely that fully evidenced guidelines could be produced. Best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. In cases where there is high risk of aspiration the potential benefits of RSI increase and thus its use is more rational.” Source location Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Open published response
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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 Robust evidence neither supports nor refutes cricoid pressure during rapid sequence induction, limiting development of definitive guidance.
Verbatim wording from the response “Your report also raised a concern regarding the “lack of updated guidelines for use of cricoid pressure and other measures to protect the airway during an RSI anaesthetic”. Like other elements of RSI, the use of cricoid force remains a controversial topic, without robust evidence to either support or refute its value⁹. The NAP4 report⁷ recommended “on balance, rapid sequence induction should continue to be taught as a standard technique for protection of the airway. Further focused research might usefully be performed to explore its efficacy, limitations and also explore the consequences of its omission.” It also suggested “to maximise the likelihood of good quality cricoid force being applied, those who perform cricoid force should be trained in its methodology, should practise at regular intervals and should consider the use of simple methods of simulation.”” Source location Response from Association of Anaesthetists - RCOA - Difficult Airways Society
Open published response
Concerns raised 1 Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Bryan Moore · 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
David Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
Wider context from the report “1. Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
” Open source report
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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 Use safety publications to share learning from Mr Moore’s death and re-promote tracheostomy guidance to members.
Verbatim wording from the response “SALG publishes regular Patient Safety Updates, which are distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. FICM publishes regular Safety” Source location Response from Response from RCOA
Open published response
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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, publish and disseminate tracheostomy-care guidance, including guidance for adjustable flanged tubes.
Verbatim wording from the response “Your prevention of future deaths report highlighted your concern regarding the “Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.” The College, FICM and ICS have worked with the NTSP to develop, publish and disseminate guidelines for tracheostomy care since 2012. This was in response to critical incident analysis research that identified recurrent themes in the management of tracheostomies in anaesthesia, critical care and hospital wards that led to patient harm. We have summarised key references below, and summarise key points from these existing documents below, with respect to general tracheostomy care and in the specific case of adjustable flanged tracheostomy tubes.” Source location Response from Response from RCOA
Open published response
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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 Participate as stakeholders in reviewing and revising tracheostomy emergency-management guidelines.
Verbatim wording from the response “The NTSP had agreed with the Difficult Airway Society in 2023 to review and revise the current guidelines for tracheostomy emergency management. The Royal College of Anaesthetists, Association of Anaesthetists, Faculty of Intensive Care Medicine and the Intensive Care Society will be stakeholders in this update, which will ensure that updated guidance will be appropriately disseminated. Other stakeholders representing the multidisciplinary team involved in tracheostomy care will also be involved, including head and neck surgery, nursing, physiotherapy, and speech and language therapy. We anticipate publication of updated guidelines in 2025. Index cases such as the case of Mr Moore help to inform updates to such guidance where necessary and we thank you for bringing this case to our attention.” Source location Response from Response from RCOA
Open published response
14 Nov 2023 Maxwell Frame · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Absence of a national policy on the placement of central venous catheters View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Association Of Anaesthetists (Great Britain & Ireland); that does not assign responsibility.
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.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations