Barts NHS Trust
NHS Trust
Action Taken
Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection ports should be used. They are also discussing with their current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. (AI summary)
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Dear Madam Coroner
Re: Regulation 28: Report to Prevent Future Deaths – Mike Fell
I write further to your prevention of future deaths notice arising from the inquest into the death of Mr Mike Fell at the Royal London Hospital. I am grateful to you for bringing the points you raise to my attention.
You raised two concerns about the use of three way taps on intravenous lines placed in central veins:
1 Whilst it is a matter of routine care to check that unused taps are closed to air, it is not recorded in Mr Fells notes that the taps had been checked and were closed. It’s unclear how or when the 3-way tap on the trauma line became open to air.
Although we regard this as routine care we have never recorded this in the notes. It is impossible to find out why this particular three way tap was left open; commonly the tap would be open to this port during injection of a drug or connection to an infusion. The tap should be closed before either the syringe is removed from the port or the infusion is removed. Less commonly the three way tap could be ‘opened’ to air by accident during movement of the patient. As a result of this incident we have re- written our policy on the use of central lines and three way taps which states that three way taps should not be used on central lines but self-sealing injection ports should be used. These are available and are in use across the trust. I enclose our up-to-date policy and a Trust wide safety notice to raise awareness of this complication and the new policy.
2 The Trauma lines used at the Royal London hospital did not come with a clamp which enabled a line not in use to be closed
These lines have been in use in the Trust for many years and the manufacturer of the line do not supply them with clamps. Currently the anaesthetic department are looking at other companies but it would appear none are made with clamps. We are discussing with our current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. Trust Executive Offices Pathology and Pharmacy 80 Newark Street Royal London Hospital London E1 2DR
Contact Telephone: 020 3246 0641
I am once again grateful to you for raising these important concerns relating to patient safety and I hope this response provides reassurance.
Kind regards
Chief Medical Officer Barts Health NHS Trust
Re: Regulation 28: Report to Prevent Future Deaths – Mike Fell
I write further to your prevention of future deaths notice arising from the inquest into the death of Mr Mike Fell at the Royal London Hospital. I am grateful to you for bringing the points you raise to my attention.
You raised two concerns about the use of three way taps on intravenous lines placed in central veins:
1 Whilst it is a matter of routine care to check that unused taps are closed to air, it is not recorded in Mr Fells notes that the taps had been checked and were closed. It’s unclear how or when the 3-way tap on the trauma line became open to air.
Although we regard this as routine care we have never recorded this in the notes. It is impossible to find out why this particular three way tap was left open; commonly the tap would be open to this port during injection of a drug or connection to an infusion. The tap should be closed before either the syringe is removed from the port or the infusion is removed. Less commonly the three way tap could be ‘opened’ to air by accident during movement of the patient. As a result of this incident we have re- written our policy on the use of central lines and three way taps which states that three way taps should not be used on central lines but self-sealing injection ports should be used. These are available and are in use across the trust. I enclose our up-to-date policy and a Trust wide safety notice to raise awareness of this complication and the new policy.
2 The Trauma lines used at the Royal London hospital did not come with a clamp which enabled a line not in use to be closed
These lines have been in use in the Trust for many years and the manufacturer of the line do not supply them with clamps. Currently the anaesthetic department are looking at other companies but it would appear none are made with clamps. We are discussing with our current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. Trust Executive Offices Pathology and Pharmacy 80 Newark Street Royal London Hospital London E1 2DR
Contact Telephone: 020 3246 0641
I am once again grateful to you for raising these important concerns relating to patient safety and I hope this response provides reassurance.
Kind regards
Chief Medical Officer Barts Health NHS Trust