PFD report

Peter Charles Tye · Prevention of Future Deaths report

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Issued 15 Feb 2016•Plymouth, Torbay and South Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Need for improvement in central venous line insertion processes
    Part of recurring concern: Unsafe management of central venous cathetersPart of recurring concern: Unsafe patient cannulation
  2. Need for improvement in central venous line removal processes
    Part of recurring concern: Unsafe management of central venous catheters
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Mandating a higher number of line-insertion procedures would not prevent this complication.

    Stated by Faculty of Intensive Care MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Need for improvement in central venous line insertion processes

Wider context from the report

“At an Inquest touching the death of Peter Charles Tye, I received evidence from ████████ that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines. Details have been shared with the Faculty of Intensive Care Medicine. In my view deaths might be reduced by the promulgation of this good practice. ”

Is this part of a recurring concern?

Yes — Unsafe management of central venous catheters; Unsafe patient cannulation.

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

Need for improvement in central venous line removal processes

Wider context from the report

“At an Inquest touching the death of Peter Charles Tye, I received evidence from ████████ that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines. Details have been shared with the Faculty of Intensive Care Medicine. In my view deaths might be reduced by the promulgation of this good practice. ”

Is this part of a recurring concern?

Yes — Unsafe management of central venous catheters.

Open source report

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

Mandating a higher number of line-insertion procedures would not prevent this complication.

Verbatim wording from the response

“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case. The spiral nature of our curriculum requires the trainee to demonstrate increasing levels of competence for this procedure resulting in a competence which would indicate that the trainee was capable of independent level practice. This is assessed by means of workplace based assessments, performed by consultant trainers who would also assess the trainee's knowledge of the indications for and complications of the procedure.”

Source location

Peter-Tye-Response
Page 1 · response
Published 15 February 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Develop arrangements to monitor incident reports.

    Stated by Faculty of Intensive Care MedicineStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2016.
  2. 2

    Develop arrangements to publicise lessons learned from incidents.

    Stated by Faculty of Intensive Care MedicineStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2016.
  3. 3

    Discuss Mr. Tye’s case at the next meeting and agree a mechanism for cascading the information.

    Stated by Faculty of Intensive Care MedicineStated plannedThe respondent said that this action was planned when they made their response on 15 February 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A standard response to inadvertent carotid puncture cannot be established because the evidence base is unclear and management must be individualized.

    Stated by Faculty of Intensive Care MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Develop arrangements to monitor incident reports.

Verbatim wording from the response

“The FICM and ICS Joint Standards Committee are currently discussing how to monitor incident reports and publicise the lessons learnt as a result of such incidents. Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed.”

Source location

Peter-Tye-Response
Page 1 · response
Published 15 February 2016

Open published response

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

Develop arrangements to publicise lessons learned from incidents.

Verbatim wording from the response

“The FICM and ICS Joint Standards Committee are currently discussing how to monitor incident reports and publicise the lessons learnt as a result of such incidents. Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed.”

Source location

Peter-Tye-Response
Page 1 · response
Published 15 February 2016

Open published response

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

Discuss Mr. Tye’s case at the next meeting and agree a mechanism for cascading the information.

Verbatim wording from the response

“The FICM and ICS Joint Standards Committee are currently discussing how to monitor incident reports and publicise the lessons learnt as a result of such incidents. Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed.”

Source location

Peter-Tye-Response
Page 1 · response
Published 15 February 2016

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

A standard response to inadvertent carotid puncture cannot be established because the evidence base is unclear and management must be individualized.

Verbatim wording from the response

“As acknowledged in the report the evidence base for dealing with inadvertent carotid artery puncture is not clear, but again we would expect this to be something that is discussed in order to demonstrate competence at this procedure. The authors of the report recognise that in Mr. Tye’s case there was little they could do to mitigate the complication once it had occurred due to the instability of the patient. This is unfortunately the nature of intensive care medicine and when patients who are critically unwell develop iatrogenic complications of any kind, management of the complication will have to be considered on an individual patient basis.”

Source location

Peter-Tye-Response
Page 1 · response
Published 15 February 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026