National Infusion and Vascular Access Society

Private and voluntary organisations · Health professional body

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First report 14 Nov 2023•Latest report 14 Nov 2023

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 National Infusion and Vascular Access Society linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire (Western)

    AI-generated summary

    Maxwell Frame · 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

    Maxwell Frame presented with sepsis caused by a pelvic abscess and bowel obstruction and underwent emergency surgery. A central venous catheter was incorrectly inserted into an artery and was later removed; clot dislodged during removal, causing strokes, after which he received palliative care and died. The report identified concern about the absence of a single national policy for central venous catheter placement.

    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 National Infusion and Vascular Access Society; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a national policy on the placement of central venous catheters

    Wider context from the report

    “Absence of a national policy on the placement of CVC’s Over the course of the inquest hearing, oral evidence was provided by several anaesthetic/ ICU doctors ranging from experienced consultants, specialty Dr’s and a Core Trainee 2 all of whom had experience to varying degrees of placing CVC’s. These Dr’s had worked in several hospitals predominantly across the Midlands and North of England. The Trust had a policy entitled Central Venous Access Device which identified the steps that I have identified earlier should have taken place but were not. I was advised by the Dr’s who gave evidence that there was no single standard policy that they had encountered nationally for the placement of CVC’s. The Trust in this case following their internal investigation of Mr Frame’s case had felt it necessary to revise their policy. Further, I was advised by some of the Dr’s who gave evidence that they felt a national policy regarding the placement of CVC’s would be beneficial. ”
    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