Recipient

Birmingham Medical School

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First report 31 Mar 2021•Latest report 31 Mar 2021

Recipient record

Reports, concerns and published responses

Other public bodies · University faculty or school. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Birmingham Medical School linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    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.

    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. The report was sent to Birmingham 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 Birmingham 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 Birmingham 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 Birmingham 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 Birmingham 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 Birmingham 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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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026