31 Mar 2021 Joan Mavis COLEY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 6 Lack of doctors' understanding of taking bloods from central lines and associated risks View source Failure to formally assess junior doctors' competence to take bloods from central lines View source Failure to formally assess and monitor doctors' procedural competence View source Limited medical school training on taking bloods from central lines and associated risks View source Failure to hand over junior doctors' procedural competencies between wards View source Lack of a standard written procedure for taking bloods from central lines View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Highlight generic and specific risks of practical procedures throughout Years 3–5 using videos, lectures, handbooks and incident scenarios.
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Action
Teach medical students the clinical significance and risks of central lines, including air embolism, through curriculum learning, cases and repeated reminders.
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Action
Refine curriculum material titles and descriptions to distinguish peripheral from central-vein procedures.
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AI-generated summary
Joan Mavis COLEY · 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
Joan Mavis COLEY, who had end stage renal failure requiring dialysis, diabetes and an infected right foot, suffered a cardiac arrest after air entered her central dialysis line while blood was being taken. She was resuscitated but subsequently developed sepsis and died on 27 November 2020. The principal concerns were inadequate training, supervision, competency assessment and handover for junior doctors taking blood from central lines, together with the absence of a clear standard operating procedure.
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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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors' understanding of taking bloods from central lines and associated risks
Wider context from the report “5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks . The basic physiology was not understood and the consultant also did not know how to take blood from this central line . Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks.
” 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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess junior doctors' competence to take bloods from central lines
Wider context from the report “2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake . As a result there was no process in place to check whether an individual doctor was competent take bloods from a central line . This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks.
” 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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess and monitor doctors' procedural competence
Wider context from the report “3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line. The doctor would learn on the job with no formal training or assessment . When moving wards if a doctor agreed to undertake a procedure it was assumed they were competent and competent . This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors.
” 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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Limited medical school training on taking bloods from central lines and associated risks
Wider context from the report “1. Medical school training: The inquest heard evidence that there is very limited training on how to take bloods from a central line, the physiology involved and potential risks . The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines.
” 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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over junior doctors' procedural competencies between wards
Wider context from the report “4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward . The junior doctor in this case was shadowing on a new ward and the Consultant in charge had no understanding of the doctors level of ability or competency . Consideration should be given to having a system to hand over ability and competencies.
” 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 Aston Medical School; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard written procedure for taking bloods from central lines
Wider context from the report “6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line . Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
” 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 Highlight generic and specific risks of practical procedures throughout Years 3–5 using videos, lectures, handbooks and incident scenarios.
Verbatim wording from the response “The lessons learned from this serious incident must be transferred to other procedures; there is potential for error and harm with respect to other procedures not currently on the GMC list. We will therefore include teaching on generic and specific risks of practical procedures throughout Years 3-5, through videos, lectures, handbooks and discussions of scenarios including serious incidents. We will ensure students understand the risks of procedures within the curriculum and are introduced to the risks of the most common procedures which they may observe but which are outwith the undergraduate curriculum.” Source location 2021-0093-Responses_Published
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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 Teach medical students the clinical significance and risks of central lines, including air embolism, through curriculum learning, cases and repeated reminders.
Verbatim wording from the response “Managing and caring for central venous lines is not included in this list for graduating medical schools; Aston Medical School will therefore focus its efforts, from Year 1, on ensuring students have a good understanding of the clinical significance of the physiology of the large central veins and how these differ from peripheral veins. In Year 3, students will be introduced to the risks associated with central lines, supported by case-based learning and throughout Years 3-5 students will be reminded of the causes of air embolism and its emergency treatment.” Source location 2021-0093-Responses_Published
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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 Refine curriculum material titles and descriptions to distinguish peripheral from central-vein procedures.
Verbatim wording from the response “As a result of our internal review of materials we have also refined titles and descriptions to highlight the difference between peripheral and central vein procedures.” Source location 2021-0093-Responses_Published
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