PFD report

Colin Foley · Prevention of Future Deaths report

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Issued 1 Apr 2026•East Riding and Hull

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Life-threatening complications associated with intravenous access devices
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.1

  1. Action

    Support NHS organisations to embed vascular-access safety principles and audit compliance to reduce avoidable harm.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.

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

  1. Position

    Existing national guidance, infection prevention standards and training resources already address vascular-access safety across the NHS.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Life-threatening complications associated with intravenous access devices

Wider context from the report

“Evidence was heard at inquest that the insertion of intravenous access devices are frequently performed procedures in clinical practice which require meticulous attention to detail, not only in their insertion and maintenance, but also in the documentation surrounding them, as well as awareness of associated complications, some of which may be life threatening, that may occur. Whilst the Hull University Teaching Hospitals have instituted on-going training which will continue in perpetuity, I believe that the NHS at large should be aware of issues that relate to these commonly performed procedures. ”

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

Support NHS organisations to embed vascular-access safety principles and audit compliance to reduce avoidable harm.

Verbatim wording from the response

“The concerns raised in Mr Foley’s case reinforce the importance of a continued national focus on vascular access safety, including education, training, and the consistent application of existing guidance. Work will continue across the NHS to support organisations in embedding these principles and auditing compliance to reduce avoidable harm associated with these commonly performed procedures.”

Source location

Response from NHS England
Page 2 · response
Published 17 April 2026

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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

Existing national guidance, infection prevention standards and training resources already address vascular-access safety across the NHS.

Verbatim wording from the response

“At a national level, established guidance already supports safe and standardised practice. The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. This includes early assessment of patients, appropriate device selection using the “Right Line” approach, daily review of device necessity, and prompt recognition and management of complications. The Framework also emphasises consideration of alternative routes of treatment where clinically appropriate.”

Source location

Response from NHS England
Page 1 · response
Published 17 April 2026

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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 all Reports to Prevent Future Deaths through the Regulation 28 Working Group and share 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 17 April 2026.

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 all Reports to Prevent Future Deaths through the Regulation 28 Working Group and share 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 Mr Foley, 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 NHS England
Page 3 · response
Published 17 April 2026

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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