Ronald CLARK · Prevention of Future Deaths report

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Issued 8 Apr 2019•Portsmouth and South East Hampshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
1

Of 2 recipients

Stated actions
2

Described in responses

Recipients and published responses

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 provide clearly differentiated packaging for stent sizes
    Part of recurring concern: Failure to ensure safety-critical medical equipment is reliably visually identifiable

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

  1. NHS England

    Review the National Safety Standards for Invasive Procedures to reduce the likelihood of Never Events.

  2. NHS England

    Update the prosthesis-verification standard to reflect developments in implant selection and verification, including potential future scanning of prostheses and implants.

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

  1. NHS England

    Packaging changes for different-sized stents are assigned to the Medicines and Healthcare products Regulatory Agency as the appropriate responsible body.

    Redirects 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 provide clearly differentiated packaging for stent sizes

Wider context from the report

“1. I was told in evidence that the stents used at the hospital are all supplied in identical packaging with only a small label identifying the size of the stents inside. I was also told that stents in this sort of packaging are in general use in most, if not all, NHS hospitals. 2. I believe action should be taken by the purchasing agencies of the NHS to ensure that stent manufacturers should supply different sizes of stents in different coloured packaging to make it easier for them to be identified during medical procedures and to obviate the risk of the wrong-sized stent being used, as was the case with Mr Clark. ”

Is this part of a recurring concern?

Yes — Failure to ensure safety-critical medical equipment is reliably visually identifiable.

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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

Review the National Safety Standards for Invasive Procedures to reduce the likelihood of Never Events.

Verbatim wording from the response

“The National Patient Safety Team, being part of NHS Improvement, is in the process of reviewing the National Safety Standards for Invasive Procedures (NatSIPPs). These are a set of high-level, national standards for all invasive procedures that have been produced to support local providers in developing and maintaining their own more detailed standardised local procedures and in order to reduce the likelihood of Never Events occurring.”

Source location

2019-0151-Response-by-NHS-England
Page 1 · response
Published 28 July 2019

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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

Update the prosthesis-verification standard to reflect developments in implant selection and verification, including potential future scanning of prostheses and implants.

Verbatim wording from the response

“The NatSIPP on prosthesis verification is being updated to reflect developments in implant selection and verification processes and will include the potential for future scanning for all prostheses/implants.”

Source location

2019-0151-Response-by-NHS-England
Page 1 · response
Published 28 July 2019

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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

Packaging changes for different-sized stents are assigned to the Medicines and Healthcare products Regulatory Agency as the appropriate responsible body.

Verbatim wording from the response

“I am grateful to you for sharing your findings from the inquest with us and highlighting that actions could prevent future deaths. The main action that you highlight relates to changes to manufacturer’s packaging so that different-sized stents are in different-coloured packaging. I note that the Regulation 28 report has also been sent to the Medicines and Healthcare products Regulatory Agency and, as changes to packaging falls within their remit, they are the more appropriate body to respond on this specific action.”

Source location

2019-0151-Response-by-NHS-England
Page 1 · response
Published 28 July 2019

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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