PFD report

Helen Elizabeth Patton · Prevention of Future Deaths report

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Issued 20 Apr 2016•Newcastle upon Tyne

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
3

Of 1 recipient

Stated actions
1

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 raised3

  1. Failure to undertake Mini Tracheostomy Procedures with ultrasound guidance or in theatre conditions
  2. Lack of national guidance for Mini Tracheostomy Procedures
  3. Risk of mortality from Mini Tracheostomy Procedures undertaken without theatre conditions or ultrasound guidance
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

    Develop ways to standardise ultrasound access training and improve its accessibility.

    Stated by Faculty of Intensive Care Medicine and Royal College of AnaesthetistsStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Mandating ultrasound for invasive airway access is not currently feasible because training is not standardised and real-time scanning is impractical.

    Stated by Faculty of Intensive Care Medicine and Royal College of AnaesthetistsUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 undertake Mini Tracheostomy Procedures with ultrasound guidance or in theatre conditions

Wider context from the report

“(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided (2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions (3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance ”

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 national guidance for Mini Tracheostomy Procedures

Wider context from the report

“(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided (2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions (3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance ”

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

Risk of mortality from Mini Tracheostomy Procedures undertaken without theatre conditions or ultrasound guidance

Wider context from the report

“(1) The Continuing risk of mortality where Mini Tracheostomy Procedures are not undertaken within theatre conditions or ultrasound guided (2) That Mini Tracheostomy Procedures are undertaken regularly on a national level without ultrasound guidance or in theatre conditions (3) The absence of any national guidance in respect of Mini Tracheostomy Procedures to minimise the risks associated with them particularly the risks of conducting such procedures outside of an operating theatre and without ultrasound guidance ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Develop ways to standardise ultrasound access training and improve its accessibility.

Verbatim wording from the response

“It is not currently feasible to mandate the use of ultrasound for invasive airway access for a number of reasons. The Intensive Care Society and the Faculty of Intensive Care Medicine are developing ways to standardise ultrasound access training in order to make it more accessible. It should be noted that ultrasound is largely limited to pre-procedure planning and landmark identification as the footprint of”

Source location

2016-0152-Response-by-The-Royal-College-of-Anaesthetists
Page 1 · response
Published 20 April 2016

Open published response

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

Mandating ultrasound for invasive airway access is not currently feasible because training is not standardised and real-time scanning is impractical.

Verbatim wording from the response

“It is not currently feasible to mandate the use of ultrasound for invasive airway access for a number of reasons. The Intensive Care Society and the Faculty of Intensive Care Medicine are developing ways to standardise ultrasound access training in order to make it more accessible. It should be noted that ultrasound is largely limited to pre-procedure planning and landmark identification as the footprint of”

Source location

2016-0152-Response-by-The-Royal-College-of-Anaesthetists
Page 1 · response
Published 20 April 2016

Open published response

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

An appropriately equipped critical care unit is considered a suitable setting because complications can be managed immediately.

Verbatim wording from the response

“However, based on data from percutaneous tracheostomy, which is likely to be a higher risk procedure than minitracheostomy, routine use of ultrasound is not mandated prior to minitracheostomy and an appropriately equipped critical care unit would be a suitable setting, as timely management of potential complications can be undertaken (i.e. immediate intubation and management of bleeding). The Faculty and College would support the NCEPOD recommendation that insertion of any device in the front of the neck access to the airway is classed as a surgical procedure. Appropriate patient assessment and planning should have taken place if the procedure was not urgent.”

Source location

2016-0152-Response-by-The-Royal-College-of-Anaesthetists
Page 1 · response
Published 20 April 2016

Open published response

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

Ultrasound is mainly limited to planning and landmark identification, while bleeding can occur with or without prior ultrasound.

Verbatim wording from the response

“However, FICM and RCOA point out that ultrasound is largely limited to pre-procedure planning and anatomic landmark identification as the size and shape of most available probes makes real-time scanning impractical. They also point out that bleeding can occur with or without prior use of ultrasound.”

Source location

2016-0152-Response-by-Department-of-Health
Page 2 · response
Published 20 April 2016

Open published response

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

Routine ultrasound before mini tracheostomy is not mandated because it is not currently feasible for several reasons.

Verbatim wording from the response

“FICM and RCOA have reviewed your Regulation 28 report and provided a joint response to the issues you raise (enclosed). They confirm that routine use of ultrasound is not mandated prior to mini tracheostomy as it is not currently feasible to do so for a number of reasons. The Intensive Care Society and FICM are developing ways to standardise ultrasound access training in order to make it more accessible.”

Source location

2016-0152-Response-by-Department-of-Health
Page 1 · response
Published 20 April 2016

Open published response

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

An appropriately equipped critical care unit is considered a suitable setting for mini tracheostomy procedures.

Verbatim wording from the response

“With regard to carrying out a mini tracheostomy procedure, FICM and RCOA confirm that an appropriately equipped critical care unit is and would be a suitable setting.”

Source location

2016-0152-Response-by-Department-of-Health
Page 2 · response
Published 20 April 2016

Open published response

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 reviews, guidance and best-practice materials address tracheostomy safety and support, so additional national guidance is not identified as necessary.

Verbatim wording from the response

“Various reviews and professional guidance have been published for England concerning the safe use of Tracheostomy and the care of patients undergoing this treatment:”

Source location

2016-0152-Response-by-Department-of-Health
Page 2 · response
Published 20 April 2016

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