Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 28
Birmingham Medical School Encourage students to undertake central-line access only under appropriate direct clinical supervision when opportunities arise.
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Sandwell and West Birmingham Hospitals NHS Trust Send Trust-wide precautions on central venous catheters and air-embolism risks to doctors.
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Sandwell and West Birmingham Hospitals NHS Trust Disseminate wider procedural-risk learning through short films and recorded presentations on the Trust intranet.
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Aston Medical School End the University of Birmingham requirement for final-year students to complete a minimum number of supervised central-line access attempts before graduation.
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General Medical Council Monitor Sandwell and West Birmingham NHS Trust and Health Education England measures to ensure appropriate actions are implemented.
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General Medical Council Continue liaising with Aston Medical School about the incident through enhanced quality-assurance activity.
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Sandwell and West Birmingham Hospitals NHS Trust Liaise with Health Education England to determine competency-assignment and supervision arrangements for clinical skills.
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Aston Medical School Highlight generic and specific risks of practical procedures throughout Years 3–5 using videos, lectures, handbooks and incident scenarios.
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Sandwell and West Birmingham Hospitals NHS Trust Provide Foundation doctors theoretical central-line education, including simulation of air embolism during blood sampling.
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Sandwell and West Birmingham Hospitals NHS Trust Write a new pictorial guideline emphasising that central-line caps and clamps must not be open simultaneously.
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Department of Health and Social Care Cascade learning from the report to Postgraduate Deans and Foundation Schools, reinforcing competency, training and supervision requirements.
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Aston Medical School Share the Aston response with the Regional Postgraduate Dean and meet the regional team.
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Aston Medical School Develop or source a standard visual reminder that central-line clamps and caps must not both be open simultaneously.
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Sandwell and West Birmingham Hospitals NHS Trust Forward clinical-skills competence summaries between rotations and require supervisors to check competency before assigning procedures.
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General Medical Council Continue working with employers, Health Education England and medical schools to monitor actions and ensure sustainable training-environment safety changes.
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Aston Medical School Teach medical students the clinical significance and risks of central lines, including air embolism, through curriculum learning, cases and repeated reminders.
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Sandwell and West Birmingham Hospitals NHS Trust Discuss procedural risks, events, learning and safety advice during weekly Clinical Supervisor–Foundation Doctor meetings.
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Department of Health and Social Care Write to UK Postgraduate Deans requesting protected-time induction, best practice and reinforcement of Foundation Professional Capability 18.
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Aston Medical School Refine curriculum material titles and descriptions to distinguish peripheral from central-vein procedures.
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Aston Medical School Emphasise the Practical Procedures 3 Question Rule and require students to obtain senior agreement before undertaking procedures outside the curriculum.
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Sandwell and West Birmingham Hospitals NHS Trust Reinforce to Trust trainees that central-line procedures are restricted to appropriately trained specialist settings and that Foundation doctors must not perform them.
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Sandwell and West Birmingham Hospitals NHS Trust Further emphasise appropriate delegation of procedures across all Trust disciplines.
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Sandwell and West Birmingham Hospitals NHS Trust Require documented competency and prohibit unsupervised procedures until trainees are signed off as competent.
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Sandwell and West Birmingham Hospitals NHS Trust Publish a central-line Learning Alert and send intermittent reminders on safe sampling processes to relevant doctors and nurses.
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Aston Medical School Discuss practical-procedure teaching and practice with Sandwell and West Birmingham Hospitals, and inform Local Education Providers about developments.
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General Medical Council Share the GMC response with local and national organisations to reinforce learning from the incident.
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General Medical Council Organise a meeting with local organisations to address the report’s identified issues.
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Sandwell and West Birmingham Hospitals NHS Trust Introduce central-line procedural-risk teaching into Trust induction and medical-student and Foundation-doctor education.
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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. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of doctors' understanding of taking bloods from central lines and associated risks
Wider context from the report “5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks . The basic physiology was not understood and the consultant also did not know how to take blood from this central line . Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to formally assess junior doctors' competence to take bloods from central lines
Wider context from the report “2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake . As a result there was no process in place to check whether an individual doctor was competent take bloods from a central line . This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to formally assess and monitor doctors' procedural competence
Wider context from the report “3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line. The doctor would learn on the job with no formal training or assessment . When moving wards if a doctor agreed to undertake a procedure it was assumed they were competent and competent . This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Limited medical school training on taking bloods from central lines and associated risks
Wider context from the report “1. Medical school training: The inquest heard evidence that there is very limited training on how to take bloods from a central line, the physiology involved and potential risks . The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to hand over junior doctors' procedural competencies between wards
Wider context from the report “4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward . The junior doctor in this case was shadowing on a new ward and the Consultant in charge had no understanding of the doctors level of ability or competency . Consideration should be given to having a system to hand over ability and competencies.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a standard written procedure for taking bloods from central lines
Wider context from the report “6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line . Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
” 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 Encourage students to undertake central-line access only under appropriate direct clinical supervision when opportunities arise.
Verbatim wording from the response “It is the intention of the University of Birmingham Medical School to continue to mandate participation of the pre-course learning content and simulated training session all final year students undertake in accessing central venous devices. Emphasis will continue to be placed on recognition and preventing and managing complications. However, it has become increasingly more difficult for students to achieve the previously required number of attempts of procedural practice in this skill as a result of COVID-19. Furthermore, it has been recognised that outside of the critical care environment there are few clinicians who are able to demonstrate the required familiarity with the procedure in order for them to clinically supervise students undertaking this skill.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send Trust-wide precautions on central venous catheters and air-embolism risks to doctors.
Verbatim wording from the response “5. General understanding of the process to follow when taking blood from a central line and the associated risks
Additional training and education will be introduced into our undergraduate and postgraduate teaching portfolio, including Trust induction, to highlight safety issues related to central venous catheters. An email has been sent to all doctors at the Trust clearly stating the precautions required when dealing with a central venous catheter including the risk of air embolism.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate wider procedural-risk learning through short films and recorded presentations on the Trust intranet.
Verbatim wording from the response “As well as addressing the specific points raised, following the Inquest hearing, we consider that there is wider learning with regard to other procedures. The risks of undertaking similar procedures or around certain incidents will be highlighted through a series of short films, recorded power points, pushed out to the doctors and loaded onto our Intranet page for quick referral.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation End the University of Birmingham requirement for final-year students to complete a minimum number of supervised central-line access attempts before graduation.
Verbatim wording from the response “Alterations to training further to the Regulation 28 report to prevent future deaths” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Sandwell and West Birmingham NHS Trust and Health Education England measures to ensure appropriate actions are implemented.
Verbatim wording from the response “Since being notified of the incident by Aston Medical School in December 2020, we have been engaging with local organisations regarding the immediate and long-term measures that will be taken to protect patients and to support those involved.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue liaising with Aston Medical School about the incident through enhanced quality-assurance activity.
Verbatim wording from the response “Aston Medical School is subject to the enhanced quality assurance measures we apply to all new medical schools, we will continue to liaise with Aston about this incident and their response to your report will feed into this quality assurance activity.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with Health Education England to determine competency-assignment and supervision arrangements for clinical skills.
Verbatim wording from the response “3. How to effectively assess and monitor competencies to undertake procedures
We will liaise with HEE to determine the optimal strategy for assigning competence to a range of clinical skills and a requirement that trainees do not undertake clinical procedures without supervision until they have been signed off as being competent, as long as these skills are included within their e-portfolio requirements for their level of training.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight generic and specific risks of practical procedures throughout Years 3–5 using videos, lectures, handbooks and incident scenarios.
Verbatim wording from the response “The lessons learned from this serious incident must be transferred to other procedures; there is potential for error and harm with respect to other procedures not currently on the GMC list. We will therefore include teaching on generic and specific risks of practical procedures throughout Years 3-5, through videos, lectures, handbooks and discussions of scenarios including serious incidents. We will ensure students understand the risks of procedures within the curriculum and are introduced to the risks of the most common procedures which they may observe but which are outwith the undergraduate curriculum.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Foundation doctors theoretical central-line education, including simulation of air embolism during blood sampling.
Verbatim wording from the response “Theoretical training will be provided to the foundation year doctors in preparation for later stages of their training, including a simulation based session on a cardiac arrest resulting from an air embolism during central vein catheter blood sampling. CMT level will receive theoretical training, skills lab and supervised training over a 3 year period. Competence is documented in the trainee’s e-portfolio by their designated clinical supervisor. This is in line with national guidelines produced by the Joint Royal College of Physicians Training Board.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write a new pictorial guideline emphasising that central-line caps and clamps must not be open simultaneously.
Verbatim wording from the response “6. Standard operating procedures for taking bloods from central lines
Documents exist on the Trust’s intranet clearly describing the correct use of central venous catheters with particular note to the risk of air embolism and how to avoid this complication.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade learning from the report to Postgraduate Deans and Foundation Schools, reinforcing competency, training and supervision requirements.
Verbatim wording from the response “• Cascade learning from your Prevention of Future Deaths report through the Postgraduate Deans/Foundation Schools, emphasising that:” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Aston response with the Regional Postgraduate Dean and meet the regional team.
Verbatim wording from the response “We will share our response to your Regulation 28 Report with the Regional Postgraduate Dean West Midlands and meet with this team. Finally the GMC is planning to meet with the University of Birmingham and Aston Medical School together, in the near future, to review the implications of your report and our responses for other medical schools.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop or source a standard visual reminder that central-line clamps and caps must not both be open simultaneously.
Verbatim wording from the response “We will develop or source a standard infogram or picture to succinctly, dramatically and repeatedly inform students that a central line must never have both the clamp and cap open at the same time.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forward clinical-skills competence summaries between rotations and require supervisors to check competency before assigning procedures.
Verbatim wording from the response “4. Handover of competencies from ward to ward
A summary of clinical skills competence will be forwarded to clinical supervisors on each rotation of junior doctors (by the junior doctor following an exit review by their current clinical supervisor) to ensure there is an awareness of skills competence and areas of lack of training.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with employers, Health Education England and medical schools to monitor actions and ensure sustainable training-environment safety changes.
Verbatim wording from the response “Our standards also require organisations to make sure that there are enough suitably qualified staff members to provide learners with appropriate clinical supervision, at all times. Supervisors must determine a learner’s level of competence, confidence and experience and provide an appropriately graded level of clinical supervision. Foundation doctors must have on-site access to a senior colleague who is suitably qualified to deal with problems that may arise during the shift.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Teach medical students the clinical significance and risks of central lines, including air embolism, through curriculum learning, cases and repeated reminders.
Verbatim wording from the response “Managing and caring for central venous lines is not included in this list for graduating medical schools; Aston Medical School will therefore focus its efforts, from Year 1, on ensuring students have a good understanding of the clinical significance of the physiology of the large central veins and how these differ from peripheral veins. In Year 3, students will be introduced to the risks associated with central lines, supported by case-based learning and throughout Years 3-5 students will be reminded of the causes of air embolism and its emergency treatment.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss procedural risks, events, learning and safety advice during weekly Clinical Supervisor–Foundation Doctor meetings.
Verbatim wording from the response “The Trust will look at identifying a list of discussion points around the previous week, focusing on procedure risks, event information, learning from others and safety advice during the weekly meetings held between Clinical Supervisors and Foundation Year Doctors.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to UK Postgraduate Deans requesting protected-time induction, best practice and reinforcement of Foundation Professional Capability 18.
Verbatim wording from the response “In addition, I welcome the actions that the UKFPO has confirmed it will take in response to the issues highlighted in your report, namely:” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refine curriculum material titles and descriptions to distinguish peripheral from central-vein procedures.
Verbatim wording from the response “As a result of our internal review of materials we have also refined titles and descriptions to highlight the difference between peripheral and central vein procedures.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise the Practical Procedures 3 Question Rule and require students to obtain senior agreement before undertaking procedures outside the curriculum.
Verbatim wording from the response “As Year 3 students begin the long clinical placements we shall emphasise the Practical Procedures 3 Question Rule (described in the Action Plan) that students must use to decide if they can undertake procedures on patients, and students will be required to seek agreement from a Specialty Trainee or Consultant if they wish to undertake a procedure not explicitly listed in the curriculum.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce to Trust trainees that central-line procedures are restricted to appropriately trained specialist settings and that Foundation doctors must not perform them.
Verbatim wording from the response “At the Trust, this guidance will be re-enforced to trainees, with the only exception to this being for those doctors undertaking specialist training on the intensive care unit. In this specialised setting, theoretical and practical training will be given during Foundation Years posts and competence confirmed by the trainees clinical supervisor in the trainee’s e-portfolio.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further emphasise appropriate delegation of procedures across all Trust disciplines.
Verbatim wording from the response “In reviewing this procedure, and the way the system let down both our junior doctor and Mrs Coley, the appropriateness of delegation was considered and reiterated to Consultants. This will be further emphasised across the Trust to all disciplines.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require documented competency and prohibit unsupervised procedures until trainees are signed off as competent.
Verbatim wording from the response “There will be a requirement for all supervising consultants to check documented competency when assigning tasks in the clinical environment. No doctor will be allowed to undertake any procedure unsupervised, at any level of training, unless they have been signed off as being competent in that clinical skill/procedure.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a central-line Learning Alert and send intermittent reminders on safe sampling processes to relevant doctors and nurses.
Verbatim wording from the response “The Patient Safety page on the intranet will evidence a ‘Learning Alert’, a pictorial reminder of the safe way of sampling from central lines, with intermittent communications on the correct processes being ‘pushed’ to doctors and nursing staff (where appropriate)” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss practical-procedure teaching and practice with Sandwell and West Birmingham Hospitals, and inform Local Education Providers about developments.
Verbatim wording from the response “To maximise the learning and impact of our action plan we will meet with Sandwell and West Birmingham Hospitals (SWBH) within the month to discuss our reports and implications for teaching and practice across the medical school and the Trust. Going forward, we will inform all our Local Education Providers of our developments within Practical Procedures through our meetings, handbooks and training sessions.” Source location 2021-0093-Responses_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the GMC response with local and national organisations to reinforce learning from the incident.
Verbatim wording from the response “We will organise a meeting with local organisations to ensure that the issues identified in your report are being satisfactorily addressed. We will also share our response to your report with local and national organisations to reinforce the learnings from this incident to prevent a similar incident happening again locally or nationally.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Organise a meeting with local organisations to address the report’s identified issues.
Verbatim wording from the response “We will organise a meeting with local organisations to ensure that the issues identified in your report are being satisfactorily addressed. We will also share our response to your report with local and national organisations to reinforce the learnings from this incident to prevent a similar incident happening again locally or nationally.” Source location 2021-0093-Responses_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce central-line procedural-risk teaching into Trust induction and medical-student and Foundation-doctor education.
Verbatim wording from the response “In light of the Coroner’s Inquest findings, as part of their induction to the Trust, procedural risks related to central venous catheter lines will be introduced to the 3rd year medical student themed week case based discussions, to 3rd, 4th and 5th years and Foundation Year Doctors.” Source location 2021-0093-Responses_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The regulator cannot mandate specific content in undergraduate medical curricula, beyond setting high-level outcomes and core practical skills.
Verbatim wording from the response “Our powers in medical education, as set out in the Medical Act 1983, are two-fold: to set the outcomes for graduates of UK medical schools leading to entry on to the medical register and to approve the curricula for postgraduate training of doctors. We quality assure both aspects of medical training against our standards for the management and delivery of medical education and training. The principle of patient safety drives our work.” Source location 2021-0093-Responses_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Central-line blood sampling should not be required of all Foundation doctors because it is specialist work requiring specific authorisation, training and direct supervision.
Verbatim wording from the response “You have advised that we should also consider including the procedure on the checklist of tasks for junior doctors. The inquest heard that the procedure is not on the checklist, which meant there was no process in place to determine individual competency.” Source location 2021-0093-Responses_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The University of Birmingham no longer requires a minimum number of supervised central-line access attempts because COVID-19 and limited suitable supervisors restricted opportunities.
Verbatim wording from the response “Alterations to training further to the Regulation 28 report to prevent future deaths” Source location 2021-0093-Responses_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National standard operating procedures for central-line blood sampling are matters for national service and education providers such as Health Education England and NHS England.
Verbatim wording from the response “Awareness of all doctors and proposal for a standard operating procedure” Source location 2021-0093-Responses_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation At the Trust, blood sampling from central venous catheters is assigned to competent nursing staff, outreach teams or medical registrars rather than Foundation doctors.
Verbatim wording from the response “Foundation Year doctors will be trained in the theoretical use of central lines but will not be allowed to undertake blood sampling, flushing, insertion nor removal of central venous catheter lines. During meetings between doctors in training and their educational supervisor, working safely within their competence level will be emphasised. Progress with the acquisition of competence in procedural skills appropriate to that level of training, will be assessed at each meeting. All doctors and medical students will be advised to avoid any clinical practical procedures that are not specifically documented in their clinical skills portfolio appropriate for their level of training.” Source location 2021-0093-Responses_Published
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