23 Oct 2013 Isabella Hope HILL · Prevention of Future Deaths report Liverpool
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Concerns raised 3 Failure of medical staff to follow UVC guidelines View source Failure to perform required x-ray confirmation of UVC position View source Inadequacy of UVC guidelines View source
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. 8
Action
Clarify the radiology service agreement to require neonatal x-rays within 60 minutes of request, 24 hours a day, seven days a week.
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Action
Extend the UVC guideline to address potential consequences of using a catheter in a non-optimal position.
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Action
Incorporate the case into all future medical staff induction programmes.
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Action
Deliver enhanced neonatal-unit education on the revised guideline.
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Action
Provide individual feedback to staff involved in the event and inform trainees’ educational supervisors where necessary.
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Action
Conduct a prospective audit of compliance with the revised UVC guideline.
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Action
Disseminate UVC complication learning and case lessons through neonatal education, inductions, shift communications, risk huddles and network meetings.
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Action
Revise and relaunch the neonatal UVC guideline requiring urgent catheter-tip assessment after unexpected deterioration.
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AI-generated summary
Isabella Hope HILL · 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
Isabella Hope HILL was born prematurely at 26 weeks and died on 17 July 2013, aged 7 days, after complications associated with an umbilical venous catheter. Total Parenteral Nutrition fluid entered her abdomen after the catheter migrated, contributing to circulatory collapse, cardiac injury and subsequent cardiac arrest. The principal concern was that the Trust’s guidelines were not followed because an x-ray to confirm the catheter’s position was not performed when it should have been, raising concern about future deaths.
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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 Liverpool Women'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to follow UVC guidelines
Wider context from the report “As can be seen from the above Narrative, the facts of this case involved the use of Central Venous Catheterisation using an Umbilical Venous Catheter [UVC]. Whilst there can be complications of UVC insertion including mal-positioning and line migration, an x-ray is required to confirm clinically the position of a UVC [which can commonly be mal-positioned despite use of optimal operation technique].
The evidence heard confirmed the Trust's own guidelines were not followed in this case in that such an x-ray was not performed at a point during Isabella's treatment when it ought to have been, and the Trust's review confirms that this not being done amounted to sub-optimal standard.
The Trust's document recommends a review of the UVC guidelines including a literature search of the UVC guidelines and discussions with senior colleagues at the other units in the practise, and of education and training around UVC guidelines.
Having concluded this inquest, and whilst I acknowledge that the Trust have indicated that changes have already been instigated, I now write to the Trust to confirm that in my view the Trust should take action because issues surrounding the UVC guidelines – particularly in the absence of any national guidelines – gives rise to a concern of deaths in the future.
I would therefore be obliged if the Trust would write to me in due course to confirm the outcome of their review once completed, setting out what is proposed in terms of changes to be made, and to explain what steps the Trust proposes to take to encourage medical staff to follow the guidelines . Perhaps the Trust would send me a copy of the full review document for my consideration once completed.
” 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 Liverpool Women'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform required x-ray confirmation of UVC position
Wider context from the report “As can be seen from the above Narrative, the facts of this case involved the use of Central Venous Catheterisation using an Umbilical Venous Catheter [UVC]. Whilst there can be complications of UVC insertion including mal-positioning and line migration, an x-ray is required to confirm clinically the position of a UVC [which can commonly be mal-positioned despite use of optimal operation technique].
The evidence heard confirmed the Trust's own guidelines were not followed in this case in that such an x-ray was not performed at a point during Isabella's treatment when it ought to have been , and the Trust's review confirms that this not being done amounted to sub-optimal standard .
The Trust's document recommends a review of the UVC guidelines including a literature search of the UVC guidelines and discussions with senior colleagues at the other units in the practise, and of education and training around UVC guidelines.
Having concluded this inquest, and whilst I acknowledge that the Trust have indicated that changes have already been instigated, I now write to the Trust to confirm that in my view the Trust should take action because issues surrounding the UVC guidelines – particularly in the absence of any national guidelines – gives rise to a concern of deaths in the future.
I would therefore be obliged if the Trust would write to me in due course to confirm the outcome of their review once completed, setting out what is proposed in terms of changes to be made, and to explain what steps the Trust proposes to take to encourage medical staff to follow the guidelines. Perhaps the Trust would send me a copy of the full review document for my consideration once completed.
” 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 Liverpool Women'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of UVC guidelines
Wider context from the report “As can be seen from the above Narrative, the facts of this case involved the use of Central Venous Catheterisation using an Umbilical Venous Catheter [UVC]. Whilst there can be complications of UVC insertion including mal-positioning and line migration, an x-ray is required to confirm clinically the position of a UVC [which can commonly be mal-positioned despite use of optimal operation technique].
The evidence heard confirmed the Trust's own guidelines were not followed in this case in that such an x-ray was not performed at a point during Isabella's treatment when it ought to have been, and the Trust's review confirms that this not being done amounted to sub-optimal standard.
The Trust's document recommends a review of the UVC guidelines including a literature search of the UVC guidelines and discussions with senior colleagues at the other units in the practise, and of education and training around UVC guidelines.
Having concluded this inquest, and whilst I acknowledge that the Trust have indicated that changes have already been instigated, I now write to the Trust to confirm that in my view the Trust should take action because issues surrounding the UVC guidelines – particularly in the absence of any national guidelines – gives rise to a concern of deaths in the future .
I would therefore be obliged if the Trust would write to me in due course to confirm the outcome of their review once completed, setting out what is proposed in terms of changes to be made, and to explain what steps the Trust proposes to take to encourage medical staff to follow the guidelines. Perhaps the Trust would send me a copy of the full review document for my consideration once completed.
” 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 Clarify the radiology service agreement to require neonatal x-rays within 60 minutes of request, 24 hours a day, seven days a week.
Verbatim wording from the response “b) The current Service Level Agreement (SLA) for Radiology with an external provider has been reviewed and clarified and now confirms that all required x-rays on neonatal patients will be performed within 60 minutes of receipt of a request, 24hrs per day and 7 days per week.” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Extend the UVC guideline to address potential consequences of using a catheter in a non-optimal position.
Verbatim wording from the response “c) Further guideline work is planned to include the potential consequences of using a central venous catheter that is not in an optimal position.” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Incorporate the case into all future medical staff induction programmes.
Verbatim wording from the response “iv. This case was included in the August medical staff induction programme and will be incorporated into all future medical staff inductions;” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Deliver enhanced neonatal-unit education on the revised guideline.
Verbatim wording from the response “What we have done to implement necessary changes:” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Provide individual feedback to staff involved in the event and inform trainees’ educational supervisors where necessary.
Verbatim wording from the response “f) Individual feedback to all staff involved in the event has taken place and where necessary the educational” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Conduct a prospective audit of compliance with the revised UVC guideline.
Verbatim wording from the response “e) A prospective audit around compliance against revised guideline is in progress;” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Disseminate UVC complication learning and case lessons through neonatal education, inductions, shift communications, risk huddles and network meetings.
Verbatim wording from the response “d) Details of possible complications of misplaced UVCs and learning points from this case were disseminated to staff during August, September, October and November 2013 as follows:” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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 Revise and relaunch the neonatal UVC guideline requiring urgent catheter-tip assessment after unexpected deterioration.
Verbatim wording from the response “b) The neonatal guideline in respect of UVCs was revised immediately and now includes the following statement: ‘Any sudden or unexpected deterioration in a baby with a central venous catheter in-situ should always prompt an urgent assessment of the position of the catheter tip. Serious complications such as pericardial effusion/cardiac tamponade or infusion of fluid into the pleural or peritoneal cavities should be excluded by x-ray or ultrasound’. The revised guideline was re-launched with the new cohort of junior medical trainees who commenced their placement in August 2013.” Source location 2013-0281-Response-by-Liverpool-Womens-NHS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations