“During the course of the evidence I was told that when patients are discharged from the…”
Dated 20 Oct 2016, from the coroner for Manchester West. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 15 Dec 2016.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated20 Oct 2016
- Deadline15 Dec 2016
- Published on judiciary.uk20 Oct 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bolton NHS Foundation TrustNamed in the report as “Bolton NHS Trust” | Response publishedPublished on judiciary.uk in October 2016. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
A. During the course of the evidence I was told that when patients are discharged from the hospital with a Hickman or central line in situ, they are not furnished with any guidance booklet or sheet as to how the said line should be monitored, cleaned, flushed etc. It is cleariy desirable that they should be as well informed as passible and I therefore consider that the provision of such written advice should be considered. B. Whilst I was satisfied that the Trust does have a clear Policy as to the provision of and use of such lines, there was clearly a lack of knowledge of this policy even amongst quite senior staff members. There shouid be consideration given to a proper continuous programme of information and education for ALL staff. C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement. There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely.
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, 2016-0372
- 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
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