“In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that…”

The coroner’s concerns

– 1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that "All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use..." 2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned. 3. However, the evidence of (author of the PSII report and consultant neurosurgeon) indicated that it was his view that the training should be mandatory, and that consideration must be given to ensuring this is rolled out in a "sustainable" way to staff both current and future - as opposed to a "knee-jerk reaction" where training is only given to a limited number of staff following an incident. 4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of "knee-jerk reaction" that was fearful of. 5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment. 6. As Coroner, it is not my role to advise what action needs to be taken - that is a matter for your organisation.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0524

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0