Chief Medical Officer for England and Wales

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First report 20 Aug 2013•Latest report 20 Aug 2013

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Chief Medical Officer for England and Wales linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester North

    AI-generated summary

    Derek BRIERLEY · 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

    Derek Brierley’s urethral catheter became blocked and attempts to recatheterise him were unsuccessful, including an abandoned suprapubic catheter insertion, after which he became acutely unwell with features of peritonitis. Concerns included the likely high insertion site, the absence of Trust guidelines on competence and training for the procedure, and difficulties locating a suprapubic catheter beforehand.

    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 Chief Medical Officer for England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Difficulties in locating suprapubic catheters before procedures

    Wider context from the report

    “3)Difficulties were encountered in locating a suprapubic catheter prior to the procedure ”
    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 Chief Medical Officer for England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Suprapubic catheter insertion at an excessively high site

    Wider context from the report

    “1) Although the consultant performing the suprapubic procedure had done so successfully on nine previous occasions the last such occasion was twelve months earlier. The family overheard instructions for the procedure being read out to the consultant whilst it was being carried out. More likely than not the site of the insertion was too high. ”
    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 Chief Medical Officer for England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Trust guidelines for competence and training in suprapubic procedures

    Wider context from the report

    “2) There are no Trust Guidelines as to the standard of competence or training of those carrying out the procedure ”
    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 Chief Medical Officer for England and Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure current competence for suprapubic procedures

    Wider context from the report

    “1) Although the consultant performing the suprapubic procedure had done so successfully on nine previous occasions the last such occasion was twelve months earlier. The family overheard instructions for the procedure being read out to the consultant whilst it was being carried out. More likely than not the site of the insertion was too high. ”
    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

Data last updated 7 September 2026