Recurance · prevention of future deaths reports
Pre-inquest brief
Misplaced central venous line
The earlier warning
Peter Tye · 15 Feb 2016 · Ian Arrow, Plymouth, Torbay and South Devon
“improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery”
What was promised
Stated action 1 · response to Peter Tye (15 Feb 2016) · stated timescale: none stated
“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.”
judiciary.uk/wp-content/uploads/2016/02/Peter-Tye-Response.pdf
What recurred
- 14 Nov 2023 · Maxwell Frame · Peter Merchant · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · Maxwell Frame · 14 Nov 2023
“Absence of a national policy on the placement of CVC's”
What happened next
No web check of the stated actions has been published for this chain.