PFD report

Michael Trevor Walton · Prevention of Future Deaths report

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Issued 4 Jul 2024•Newcastle and North Tyneside

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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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 raised1

  1. Failure to ensure availability of appropriate cannulae without supply shortages
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Develop defined triggers for NHS Resilience involvement in medical supply disruptions.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
  2. Action

    Operate the National Supply Disruption Response to help resolve escalated medical-equipment supply disruptions.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Local organisations, not NHS Supply Chain, must decide whether listed alternative medical products are suitable for use.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 ensure availability of appropriate cannulae without supply shortages

Wider context from the report

“(1) The surgeon’s preferred choice of cannula was not available for the procedure due to supply issues. (2) A cannula with a shorter tip was therefore used for the procedure. (3) The cannula type contributed to its dislodgement from the lumen of the aorta and to Mr Walton’s death. (4) An arterial catheter is a basic and inexpensive medical device used daily in a hospital setting. (5) Operating surgeons are best placed to decide on the most appropriate equipment to use and should not be restricted in that choice by supply shortages. (6) Using sub-optimal medical equipment poses an avoidable risk to patients of significant harm including death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Develop defined triggers for NHS Resilience involvement in medical supply disruptions.

Verbatim wording from the response

“Nationally, NHS Resilience gets involved in supply disruptions where they receive an escalation. These come in from either NHS Trusts (via NHS England’s Emergency Preparedness, Resilience and Response (EPRR) Teams), the Department of Health and Social Care’s (DHSC’s) National Supply Disruption Response (NSDR) Team or, less frequently, from NHS Supply Chain or NHS England’s Patient Safety Team.”

Source location

Response from NHSE
Page 1 · response
Published 4 July 2024

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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

Operate the National Supply Disruption Response to help resolve escalated medical-equipment supply disruptions.

Verbatim wording from the response

“The NSDR has been in place since December 2019 and acts as a single point of contact when an NHS Trust is experiencing supply disruption and has not been able to mitigate the disruption. Once a disruption has been reported to the NSDR, the Department will then work to help resolve the matter, including by:”

Source location

Response from DHSC
Page 2 · response
Published 4 July 2024

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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

Local organisations, not NHS Supply Chain, must decide whether listed alternative medical products are suitable for use.

Verbatim wording from the response

“NHS Supply Chain’s listing of alternative products is limited in scope and does not constitute advice. Decisions on the use of alternative products must be taken at local level.”

Source location

Response from NHSE
Page 2 · response
Published 4 July 2024

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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

No national escalation or DHSC referral was identified for the cannula shortage as causing operational or patient-safety risks.

Verbatim wording from the response

“Regarding this specific case and the Medtronic cannula product that was unavailable, NHS England does not believe (from a search dating back to 2021) that there was any escalation of a shortage to the national team, nor a referral from DHSC’s NSDR”

Source location

Response from NHSE
Page 1 · response
Published 4 July 2024

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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

Established supply-disruption guidance, escalation processes and the National Supply Disruption Response are available to mitigate patient risks.

Verbatim wording from the response

“Medical supply chains are complex, global and highly regulated, making them vulnerable to a variety of shocks. Whilst we cannot always prevent supply disruption from occurring, there are a range of well-established processes and tools in place to help manage them when they do arise, and to help mitigate risks to patients.”

Source location

Response from DHSC
Page 2 · response
Published 4 July 2024

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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.1

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Available evidence indicates the cannula used was acceptably safe and showed no excess risk when used as intended.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    NHS England will provide information on actions taken by the NHS Trust following the concerns about the death.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Michael, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHSE
Page 2 · response
Published 4 July 2024

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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

Available evidence indicates the cannula used was acceptably safe and showed no excess risk when used as intended.

Verbatim wording from the response

“I understand from the MHRA that central arterial cannula are acceptably safe when used as intended. Unfortunately, rare complications do still occur during interventional procedures. The MHRA have analysed available data and past records up to and including 17 July 2024 and are not aware of any excess risk with the cannula used for Mr Walton’s procedure. For all devices on the UK market, the manufacturer must submit vigilance reports to the MHRA when reportable incidents that involve their device occur in the UK. The manufacturer must also take appropriate safety action when required and ensure their device meets appropriate standards of safety and performance for as long as it is in use.”

Source location

Response from DHSC
Page 2 · response
Published 4 July 2024

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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

NHS England will provide information on actions taken by the NHS Trust following the concerns about the death.

Verbatim wording from the response

“Thank you for the additional time provided to the Department to provide a response to the concerns raised in the report. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE), the Medicines and Healthcare products Regulatory Agency (MHRA) and the Care Quality Commission (CQC). I understand that you have also requested a response from NHS England, which will provide information on the specific actions taken by the Newcastle upon Tyne Hospitals NHS Foundation Trust following the concerns you have raised about Mr Walton’s death.”

Source location

Response from DHSC
Page 1 · response
Published 4 July 2024

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