“In addition to the circumstances described above, as part of my investigation I was made…”

The coroner’s concerns

In addition to the circumstances described above, as part of my investigation I was made aware of a second similar incident which occurred on 11 December 2025 at the Boston Dialysis Centre. That Centre is also operated by University Hospitals of Leicester NHS Trust. Within that second incident there was an apparent disconnection of the CVC, giving rise to blood loss in similar circumstances to the incident with Mr Rowley. Fortunately, the patient in that incident was successfully treated and there was no further loss of life. That patient was also fitted with a Covidien Palindrome Chronic Dual Lumen Catheter. The Batch number was 230200134. As part of my investigation, I seized the CVC used by each of these two patients. I arranged for those to be examined by an independent Consultant Nephrologist. I have now received a preliminary report. Whilst that is not currently in a form that I can disclose, the relevant section of that report in relation to the death of Mr Rowley states: “The CVC consists of a number of parts that are assembled during the manufacturing process. The two ports consist of a brown and a blue plastic Luer Lock connector permanently bonded to silicone rubber tubes that enter the ‘Y’ shaped connector. A white plastic sleeve is present at the point the ports enter the rubber tubing. These ports are not intended to ever be removed or detached from the silicone rubber tubes. The integrity of the permanent bond between the ports and the tubing is essential for the safety of the CVC. [Mr Rowley] died due to exsanguination caused by a mechanical failure of the CVC. The direct cause was failure of the bond between the venous port of the CVC and the tubing, allowing the port to detach thereby causing blood returning from the machine to the patient to be expelled.” In relation to the later incident of 11 December 2025, the relevant section of the preliminary report states: “The nature of the failure of this CVC appears to be identical to that of Mr Rowley, namely detachment of one port of the CVC from the silicone rubber tube. The direct cause was failure of the bond between the venous port of the CVC and the tubing, allowing the port to detach thereby causing blood returning from the machine to the patient to be expelled. The nature of the failure appears identical…” The report concludes that: “I am concerned that these events could represent a more widespread vulnerability of this brand or batch of dialysis lines and recommend reporting these events to the Medicines and Healthcare products Regulatory Agency (MHRA).” I endorse those concerns.

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, 2026-0192

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