“During the Inquest evidence was heard that: i”

The coroner’s concerns

1. During the Inquest evidence was heard that: i. A haemorrhage following the removal of a central venous catheter is a rare, but known, complication of the removal of a central venous catheter and the complication has never been seen by many experienced Renal Physicians, including the 3 Renal Physicians giving evidence at the Inquest. ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter. iii. Following the death of the Deceased the Salford Royal NHS 3 Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications. A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter. The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death. The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time. iv. There are no national guidelines in relation to the removal of central venous catheters, particularly temporary central venous catheters for haemodialysis. The evidence at the Inquest confirmed that the Secretary of State, the Renal Association, the British Renal Society and the Intensive Care Society would be appropriate organisations to consider the issue of a national policy, protocol and guidance relating to the removal of central venous catheters. v. The evidence of the Physiotherapist in relation to changing the author times of notes on the central computer note system at the Salford Royal NHS Foundation Trust was not believed to be possible by representatives of the Hospital Trust attending the Inquest but the Physiotherapist was adamant, in her evidence, that she changed the times, which was her usual procedure, so that the author time recorded by her represented the time of the action taken by her rather than the time of the note made by her. 2. I request the Secretary of State for Health, the Renal Association, the British Renal Society and the Intensive Care Society to review the policies and protocols in relation to the removal of central venous catheters and to consider the issue of national guidelines relating to the removal of catheters. The review should consider the constant visual observation of a patient for a period of one hour following the removal of the catheter, particularly in view of the extent of blood loss which 4 may arise if a patient is left on their own for periods of 5 minutes following the removal of the catheter. 3. I request the Salford Royal NHS Foundation Trust to further review the policy and protocols together with the quick reference guide to consider the constant visual observation of a patient for a period of one hour following the removal of a central venous catheter to prevent extensive blood loss and to prevent future deaths. I acknowledge that a considerable amount of work has been done by the Salford NHS Foundation Trust, but I request a further review to cover the above matters of concern. 4. 6 I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note. The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored.

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

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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