NHS England
NHS / Health Body
Action Taken
• NHS England stated that established guidance already supports safe and standardised practice for the insertion and management of intravenous (IV) access devices. • The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. • National infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National guidance. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Colin Foley who died on 28th June 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st April 2026 concerning the death of Colin Foley on 28th June 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Foley’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Foley’s care have been listened to and reflected upon.
Your Report raises concerns regarding the insertion of intravenous access devices, their maintenance and the documentation surrounding them. You were concerned that awareness needed raising to the NHS at large of their associated complications, which may be life threatening. Infection Prevention Control The NHS recognises that the insertion and management of intravenous (IV) access devices are among the most commonly performed clinical procedures but are not without risk. These procedures require a high level of technical competence, careful clinical decision-making, and accurate documentation. Complications associated with vascular access devices, including infection and device failure, can in some cases be serious or life-threatening. At a national level, established guidance already supports safe and standardised practice. The UK Vessel Health and Preservation (VHP) Framework (2020)promotes a proactive, evidence-based approach to vascular access. This includes early assessment of patients, appropriate device selection using the “Right Line” approach, daily review of device necessity, and prompt recognition and management of complications. The Framework also emphasises consideration of alternative routes of treatment where clinically appropriate. In addition, national infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
8th May 2026
the essential elements required during insertion and maintenance of vascular access devices. These measures are designed to reduce the risk of harm, particularly device- related infection, and rely on consistent application in all care settings. The Device-Related Infection Prevention Practice (DRIPP) improvement collaborative (2019) has further supported this work at a national level by developing and promoting evidence-based resources and shared learning to strengthen practice across organisations. The concerns raised in Mr Foley’s case reinforce the importance of a continued national focus on vascular access safety, including education, training, and the consistent application of existing guidance. Work will continue across the NHS to support organisations in embedding these principles and auditing compliance to reduce avoidable harm associated with these commonly performed procedures. In addition, there is specific learning supported by NHS England through the NHS Learning Hub and the e-Learning for Health site which both contain a training package known as the IV Therapy Passport. The passport contains several parts to support best practice for intravenous access including:
• An introduction to IV therapy
• The intravenous route
• Vascular access devices
• Risks and complications of intravenous therapy
• Fluids and electrolytes in intravenous therapy
• Preparation and administration of intravenous medicines
• Drug calculations in intravenous therapy There is also a portal option to provide feedback on the content which was last updated in October 2025. We trust this response provides assurance that this area is recognised and addressed at a national level. Nursing Nursing staff responsibilities for patients with IV access devices include daily inspection before each access or whenever the patient reports pain or discomfort, maintaining clean, dry, intact dressings, use of aseptic non touch technique for access and flushing and prompt escalation and removal if concerns identified. The cannula should be changed only when clinically indicated and includes checking for: pain, redness, swelling, exudate, signs of infection or phlebitis and secure dressing and patency. This should be clearly documented in the patient’s medical records. Insertion bundles emphasise the use of aseptic non touch technique (ANTT), effective hand hygiene, appropriate skin antisepsis (chlorhexidine alcohol preparation with sufficient drying time), correct site and device selection, securement, and comprehensive documentation of insertion details. The evidence base shows that omission or inconsistent application of any individual element increases the risk of local infection and treatment failure, particularly in frail older adults.
From a nursing perspective, peripheral intravenous cannula (PIVC) care is best understood as an intervention, requiring structured systems and a consistent application of evidence-based practice. National guidance describes this as a safety critical nursing activity requiring meticulous attention to detail throughout the full life cycle of the device: insertion, ongoing assessment, maintenance, and timely removal. National frameworks recognise that safe IV care is influenced not only by individual competence, but by organisational systems, including education, competency assessment, audit, staffing, and leadership oversight. In high acuity areas caring for frail older adults, nurses must frequently manage multiple intravenous devices alongside competing clinical priorities. Standardised bundles, supported by ongoing training and audit, are therefore essential to safeguard quality and reduce reliance on informal practice variation. The Royal College of Nursing’s Standards for Infusion Therapy states that nurses are professionally accountable for safe management of intravenous therapy, including assessment, documentation, escalation and removal, while also recognising that organisations hold responsibility for ensuring staff are trained, competent and supported by clear policies. The Nursing and Midwifery Council (NMC) reinforces that employers must provide systems, staffing, education and resources that enable nurses to practise safely, and that failures in care often arise from system pressures rather than individual error.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Foley, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st April 2026 concerning the death of Colin Foley on 28th June 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Foley’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Foley’s care have been listened to and reflected upon.
Your Report raises concerns regarding the insertion of intravenous access devices, their maintenance and the documentation surrounding them. You were concerned that awareness needed raising to the NHS at large of their associated complications, which may be life threatening. Infection Prevention Control The NHS recognises that the insertion and management of intravenous (IV) access devices are among the most commonly performed clinical procedures but are not without risk. These procedures require a high level of technical competence, careful clinical decision-making, and accurate documentation. Complications associated with vascular access devices, including infection and device failure, can in some cases be serious or life-threatening. At a national level, established guidance already supports safe and standardised practice. The UK Vessel Health and Preservation (VHP) Framework (2020)promotes a proactive, evidence-based approach to vascular access. This includes early assessment of patients, appropriate device selection using the “Right Line” approach, daily review of device necessity, and prompt recognition and management of complications. The Framework also emphasises consideration of alternative routes of treatment where clinically appropriate. In addition, national infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
8th May 2026
the essential elements required during insertion and maintenance of vascular access devices. These measures are designed to reduce the risk of harm, particularly device- related infection, and rely on consistent application in all care settings. The Device-Related Infection Prevention Practice (DRIPP) improvement collaborative (2019) has further supported this work at a national level by developing and promoting evidence-based resources and shared learning to strengthen practice across organisations. The concerns raised in Mr Foley’s case reinforce the importance of a continued national focus on vascular access safety, including education, training, and the consistent application of existing guidance. Work will continue across the NHS to support organisations in embedding these principles and auditing compliance to reduce avoidable harm associated with these commonly performed procedures. In addition, there is specific learning supported by NHS England through the NHS Learning Hub and the e-Learning for Health site which both contain a training package known as the IV Therapy Passport. The passport contains several parts to support best practice for intravenous access including:
• An introduction to IV therapy
• The intravenous route
• Vascular access devices
• Risks and complications of intravenous therapy
• Fluids and electrolytes in intravenous therapy
• Preparation and administration of intravenous medicines
• Drug calculations in intravenous therapy There is also a portal option to provide feedback on the content which was last updated in October 2025. We trust this response provides assurance that this area is recognised and addressed at a national level. Nursing Nursing staff responsibilities for patients with IV access devices include daily inspection before each access or whenever the patient reports pain or discomfort, maintaining clean, dry, intact dressings, use of aseptic non touch technique for access and flushing and prompt escalation and removal if concerns identified. The cannula should be changed only when clinically indicated and includes checking for: pain, redness, swelling, exudate, signs of infection or phlebitis and secure dressing and patency. This should be clearly documented in the patient’s medical records. Insertion bundles emphasise the use of aseptic non touch technique (ANTT), effective hand hygiene, appropriate skin antisepsis (chlorhexidine alcohol preparation with sufficient drying time), correct site and device selection, securement, and comprehensive documentation of insertion details. The evidence base shows that omission or inconsistent application of any individual element increases the risk of local infection and treatment failure, particularly in frail older adults.
From a nursing perspective, peripheral intravenous cannula (PIVC) care is best understood as an intervention, requiring structured systems and a consistent application of evidence-based practice. National guidance describes this as a safety critical nursing activity requiring meticulous attention to detail throughout the full life cycle of the device: insertion, ongoing assessment, maintenance, and timely removal. National frameworks recognise that safe IV care is influenced not only by individual competence, but by organisational systems, including education, competency assessment, audit, staffing, and leadership oversight. In high acuity areas caring for frail older adults, nurses must frequently manage multiple intravenous devices alongside competing clinical priorities. Standardised bundles, supported by ongoing training and audit, are therefore essential to safeguard quality and reduce reliance on informal practice variation. The Royal College of Nursing’s Standards for Infusion Therapy states that nurses are professionally accountable for safe management of intravenous therapy, including assessment, documentation, escalation and removal, while also recognising that organisations hold responsibility for ensuring staff are trained, competent and supported by clear policies. The Nursing and Midwifery Council (NMC) reinforces that employers must provide systems, staffing, education and resources that enable nurses to practise safely, and that failures in care often arise from system pressures rather than individual error.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Foley, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.