Recipient

Chief Medical Officer for England and Wales

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First report 20 Aug 2013•Latest report 20 Aug 2013

Recipient record

Reports, concerns and published responses

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
0

Across all linked responses

Stated actions
0

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
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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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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
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