Joan Coley
31 Mar 2021 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. taking bloods from central line
“very limited training on how to take bloods from a central line, the physiology involved and potential risks”
2. absence of checklist for central line blood draws
“taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake”
3. lack of competence assessment for central line blood draws
“there was no formal system for assessing a doctor's competence to 5 undertake a particular task for example, taking bloods from a central line”
4. inadequate handover of competency between wards
“there was no system of hand over when junior doctors change from ward to ward”
5. lack of understanding of central line blood draw risks
“general lack of understanding of how to take bloods from a central line and the associated risks”
6. absence of standard operating procedure for central line blood draws
“no standard written procedure for taking bloods from a central line”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
This report
“The inquest heard how there was no system of hand over when junior doctors change from ward to ward.”
Responses
2021-0093-Responses_Published.pdf ↗· Department of Health and Social Care
Stated action · 2021
“Write to all UK Postgraduate Deans to request that they ensure their induction programmes for Foundation doctors are in protected time; include best practice; and, reinforce the requirements of Foundation Professional Capability 18: recognises and works within limits of personal competence;”