Misplaced central venous line
Department of Health and Social Care received 2 coroners' reports about this hazard between 15 Feb 2016 and 14 Nov 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case.”
- 7 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“Absence of a national policy on the placement of CVC's”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2016 → 2023Maxwell Frame7 years 9 months after Peter Tye · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern risks associated with central venous catheter placement. The earlier report focuses on preventing misplacement through local improvements, while the later report highlights the lack of a national standard policy.
Peter Tye · 15 Feb 2016
“improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery”
Original on judiciary.uk ↗ Maxwell Frame · 14 Nov 2023
“Absence of a national policy on the placement of CVC's”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case.”
Stated action
“The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2023 | 0.61 | 0.17 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.