PFD report

THOMAS ADRIAN BURROUGHS · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 12 Dec 2024•Essex

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
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Failure to promptly remove an unused Hickman catheter
    Part of recurring concern: Unsafe management of central venous catheters
  2. Failure to report a split Hickman catheter through the required incident-reporting process
    Part of recurring concern: Unreliable reporting of patient-safety incidents
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.8

  1. Action

    Report the delay in Hickman line removal retrospectively to identify issues and necessary preventive action.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
  2. Action

    Issue a Patient Safety update highlighting incident-reporting requirements and incident-record management.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
  3. Action

    Use senior-leader briefings to disseminate incident-reporting expectations, including reporting equipment failures, near misses and no-harm incidents.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.

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 promptly remove an unused Hickman catheter

Wider context from the report

“(3) Mr Burroughs had a jejunal extension to his PEG on 15 January 2024. Advice was received that the Hickman Catheter should be removed as soon as possible if it was not being used. (4) Mr Burroughs was tachycardic and spiked a temperature on 19 January 2024 with no apparent symptoms of recurrent aspiration and the Hickman Line remained in situ. (5) The Hickman Catheter was surgically removed on 30 January 2024. ”

Is this part of a recurring concern?

Yes — 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 report a split Hickman catheter through the required incident-reporting process

Wider context from the report

“(2) The incident was escalated for urgent medical review due to the significant risk of infection, however no Datix was raised for the split Hickman Catheter as required by the acute Trust protocol. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

Open source report

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

Report the delay in Hickman line removal retrospectively to identify issues and necessary preventive action.

Verbatim wording from the response

“We recognise that Mr Burroughs case identified non-adherence/awareness of the CVAD policy by clinicians across specialties, and specifically at the resident surgeon level. We have retrospectively raised an incident for the delay in removal of the line so that we can identify the issues and take the necessary action to avoid recurrence.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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

Issue a Patient Safety update highlighting incident-reporting requirements and incident-record management.

Verbatim wording from the response

“In addition to this, the Patient Safety team issued an ‘MSE Patient Safety update’ during the week commencing 13th January 2024, highlighting the importance of reporting incidents, and our expectations on how the incident record should be managed.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

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

Use senior-leader briefings to disseminate incident-reporting expectations, including reporting equipment failures, near misses and no-harm incidents.

Verbatim wording from the response

“Each month we hold in-person Senior Leader’s briefing sessions on all our acute hospital sites. The purpose of these briefings is to share key messages to senior colleagues, and the expectation is for these messages to be cascaded to all teams across all trust sites.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

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

Cascade immediate and reflective learning from the catheter incident to involved, ward, medical and surgical staff.

Verbatim wording from the response

“We acknowledge regrettably on this occasion there was a failure by staff to raise an incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) for the split Hickman line. A retrospective incident has since been reported with immediate learning identified and cascaded to all staff. We have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the correct process is for the clinical team raise an incident and report it to the MHRA. Reflective learning has been taken by the individual staff involved, as well as the nursing staff from Edith Cavell Ward, and the wider medical and surgical wards.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 18 December 2024

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

Report the split Hickman catheter incident retrospectively through the Trust’s electronic incident-reporting system.

Verbatim wording from the response

“We acknowledge regrettably on this occasion there was a failure by staff to raise an incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) for the split Hickman line. A retrospective incident has since been reported with immediate learning identified and cascaded to all staff. We have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the correct process is for the clinical team raise an incident and report it to the MHRA. Reflective learning has been taken by the individual staff involved, as well as the nursing staff from Edith Cavell Ward, and the wider medical and surgical wards.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 18 December 2024

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

Reinforce incident-reporting requirements through ward meetings and Elevate training or refresher training for staff.

Verbatim wording from the response

“On 23 December 2024 and 29th January 2025 staff meetings were held on Edith Cavell Ward, (the location of the split Hickman line incident), to discuss Mr Burrough’s experience in detail and identify learning opportunities. All staff were reminded of the Trust’s expectations around incident reporting, and the requirement to complete their incident reporting training on the Trusts electronic training platform, ‘Elevate’. Staff who were already compliant were directed to complete refresher training on incident reporting where required.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

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

Present the Hickman line case to the vascular governance team and reinforce timely removal and compliance with the central venous access policy.

Verbatim wording from the response

“On 16 January 2025, the Clinical Director for Vascular Services, ████████ presented Mr Burroughs’ case to the vascular governance team meeting and discussed the need to remove indwelling lines as soon as possible, (within the limitations of theatre access and emergency case prioritisation). Attention was drawn to the CVAD policy and the importance of compliance to ensure patient safety.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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

Remind inpatient adult wards to access the central venous access policy and remove Hickman lines promptly.

Verbatim wording from the response

“Communications have also been sent to all inpatient adult wards reminding staff to access the CVAD policy reiterating the importance of the timely removal of Hickman lines.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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

    Report the Hickman catheter malfunction retrospectively to the MHRA.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
  2. 2

    Present the PFDR concerns at the Trust’s next audit day to raise awareness and maintain compliance.

    Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  3. 3

    Notify inpatient adult wards about actions for line fractures and provide access to the central venous access policy.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.

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

Report the Hickman catheter malfunction retrospectively to the MHRA.

Verbatim wording from the response

“We acknowledge regrettably on this occasion there was a failure by staff to raise an incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) for the split Hickman line. A retrospective incident has since been reported with immediate learning identified and cascaded to all staff. We have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the correct process is for the clinical team raise an incident and report it to the MHRA. Reflective learning has been taken by the individual staff involved, as well as the nursing staff from Edith Cavell Ward, and the wider medical and surgical wards.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 18 December 2024

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

Present the PFDR concerns at the Trust’s next audit day to raise awareness and maintain compliance.

Verbatim wording from the response

“Further, it is our intention for the concerns raised in this PFDR report to be presented at the trust’s next audit day which is attended by staff of all grades to raise awareness of the issues and maintain compliance.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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

Notify inpatient adult wards about actions for line fractures and provide access to the central venous access policy.

Verbatim wording from the response

“Communication has been sent to all our inpatient adult wards raising awareness of what action should be taken if they identify a case of line fracture, and details of how to access our ‘MSEPO-23026 Central venous access in adults’ (CVAD) policy included for ease of reference. This policy provides detailed guidance for management of central venous access lines, and how to manage the line if issues arise. This is a current policy in place, accessible to all staff.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

Open published response
Back to top

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