“Medical school training: The inquest heard evidence that there is very limited training…”
Dated 31 Mar 2021, from the coroner for Birmingham and Solihull. Sent to 6 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 26 May 2021. A reply may have been sent and not yet published.
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.
- Report dated31 Mar 2021
- Deadline26 May 2021
- Published on judiciary.uk1 Apr 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sandwell and West Birmingham Hospitals NHS Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Birmingham Medical School | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Aston Medical School | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Department of Health and Social Care | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| General Medical Council | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| UK Foundation Programme | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. Medical school training: The inquest heard evidence that there is very limited training on 5 how to take bloods from a central line, the physiology involved and potential risks. The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines. 2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake. As a result there was no process in place to check whether an individual doctor was competent take take bloods from a central line. This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks. 3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line The doctor would learn on the job with no formal training or assessment. When moving wards if a doctor agreed to undertake a procedure it was assumed they were capable and competent. This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors. 4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward. The junior doctor in this case was shadowing on a new ward and the Consultant in change had no understanding of the doctors level of ability or competency. Consideration should be given to having a system to hand over ability and competencies. 5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks. The basic physiology was not understood and the consultant also did not know how to take blood from this central line. Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks. 6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line. Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
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, 2021-0093
- 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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