PFD report

Colin Garth · Prevention of Future Deaths report

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Issued 20 Oct 2016•Manchester West

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised4

  1. Lack of written discharge guidance for monitoring, cleaning and flushing Hickman or central lines
    Part of recurring concern: Unreliable hospital discharge documentationPart of recurring concern: Unsafe management of central venous catheters
  2. Failure to refer a faulty syringe driver for repair or replacement before reconnection
  3. Lack of staff knowledge of the policy for provision and use of Hickman or central lines
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 written discharge guidance for monitoring, cleaning and flushing Hickman or central lines

Wider context from the report

“A. During the course of the evidence I was told that when patients are discharged from the hospital with a Hickman or central line in situ, they are not furnished with any guidance booklet or sheet as to how the said line should be monitored, cleaned, flushed etc. It is clearly desirable that they should be as well informed as possible and I therefore consider that the provision of such written advice should be considered. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; Unsafe management of central venous catheters.

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 refer a faulty syringe driver for repair or replacement before reconnection

Wider context from the report

“C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement. There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of staff knowledge of the policy for provision and use of Hickman or central lines

Wider context from the report

“B. Whilst I was satisfied that the Trust does have a clear Policy as to the provision of and use of such lines, there was clearly a lack of knowledge of this policy even amongst quite senior staff members. There should be consideration given to a proper continuous programme of information and education for ALL staff. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 of syringe driver equipment to sound a fault alarm

Wider context from the report

“C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement. There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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