The Society Of British Neurological Surgeons

Private and voluntary organisations · Registered charity

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First report 24 Oct 2023•Latest report 30 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: 2
Published responses: 100%
Concerns addressed: 3
Stated actions: 2

Concerns and recipient responses

Statements from The Society Of British Neurological Surgeons linked to the concerns in each report. Select any concern, action or position to view the source wording.

30 Nov2023
Liverpool and the Wirral
Concerns raised2
1. Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate
2. Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues
Actions described in response 1
1. Action
  Obtain permission to share the Plymouth EVD management SOP with clinical leads on request.
Respondent positions 1
1. Position
  Individual Trusts are responsible for reviewing or developing local EVD standard operating procedures where necessary.
  Redirects responsibility
AI-generated summary

Katherine Sarah FLYNN · 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

Katherine Sarah Flynn, aged 34, underwent surgery for a malignant brain tumour and subsequently became dependent on an external ventricular drain. She died on 6 March 2022 after the drain stopped draining, hydrocephalus developed, and the drain was found to have dislodged. Concerns included failures to escalate reduced drainage and leakage to the medical team, and unclear guidance on escalation when a drain stopped draining but continued to oscillate.

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 The Society Of British Neurological Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate
Wider context from the report
“The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating. Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue. This is a risk which needs to be highlighted at a national level. ”
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 The Society Of British Neurological Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues
Wider context from the report
“The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating. Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue. This is a risk which needs to be highlighted at a national level. ”
Open source report
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
Obtain permission to share the Plymouth EVD management SOP with clinical leads on request.

Verbatim wording from the response
“Following the Coroner’s Report we ask you to review any SOP, or develop a SOP for your unit where necessary. Colleagues in Plymouth developed an SOP for the management of EVDs in Intensive Care. While this Regulation 28 will initiate review I have obtained permission from the authors for this to be shared with the Clinical Leads on request (to Suzanne).”

Source location
Response from Society of British Neurological Surgeons
Page 1 · response
Published 6 December 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Individual Trusts are responsible for reviewing or developing local EVD standard operating procedures where necessary.

Verbatim wording from the response
“Following the Coroner’s Report we ask you to review any SOP, or develop a SOP for your unit where necessary. Colleagues in Plymouth developed an SOP for the management of EVDs in Intensive Care. While this Regulation 28 will initiate review I have obtained permission from the authors for this to be shared with the Clinical Leads on request (to Suzanne).”

Source location
Response from Society of British Neurological Surgeons
Page 1 · response
Published 6 December 2023
Open published response
24 Oct2023
South Yorkshire (Western)
Concerns raised1
1. Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Actions described in response 1
1. Action
  Disseminate the case précis and surgical safety advice to members performing amygdalohippocampectomy.
AI-generated summary

Tracy Gambrill · 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

Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.

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 The Society Of British Neurological Surgeons; that does not assign responsibility.
PFD Monitor interpretation
Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position. I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation. ”
Open source report
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 the case précis and surgical safety advice to members performing amygdalohippocampectomy.

Verbatim wording from the response
“On considering the coroner’s report, I consider that sharing a précis of the case, as presented to me, is appropriate so that points raised by the coroner can be considered by members performing amygdalohippocampectomy.”

Source location
Response from Society of British Neurological Surgeons
Page 1 · response
Published 1 November 2023
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate

Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues

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.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised1

Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times

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.1

Actions described in response 1

Respondent positions 1

Actions described in response 1