Thomas Burroughs

H.M Area Coroner 
Ms Sonia Hayes 
SEAX House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

Our Ref: 

6 February 2025 

Dear Ms Hayes 

Regulation 28 Report to Prevent Future Deaths – Thomas Burroughs 

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 12th 
December 2024, relating to the part-heard Inquest of Mr Thomas Burroughs. 

We have considered your concerns and set out our formal response to each matter using 
your numbering as follows. 

Matters of Concern 

Incident reporting  

(1) On 13 January 2024 acute Trust Hospital ward staff noted a split in the lumen 

of the Hickman Catheter and this was clamped and dressed.  

(2) The incident was escalated for urgent medical  review due to the significant 
risk of infection, however no Datix was raised for the split Hickman Catheter 
as required by the acute Trust protocol. 

We  acknowledge  regrettably  on  this  occasion  there  was  a  failure  by  staff  to  raise  an 
incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) 
for  the  split  Hickman  line.  A  retrospective  incident  has  since  been  reported  with 
immediate  learning  identified  and  cascaded  to  all  staff.  We  have  also  retrospectively 
reported  the  incident  to  the  Medicines  and  Healthcare  Products  Regulatory  Agency 
(MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the 
correct  process  is  for  the  clinical  team  raise  an  incident  and  report  it  to  the  MHRA.  
Reflective learning has been taken by the individual staff involved, as well as the nursing 
staff from Edith Cavell Ward, and the wider medical and surgical wards. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On 23 December 2024 and 29th January 2025 staff meetings were held on Edith Cavell 
Ward,  (the  location  of  the  split  Hickman  line  incident),  to  discuss  Mr  Burrough’s 
experience  in  detail  and  identify  learning  opportunities.  All  staff  were  reminded  of  the 
Trust’s  expectations  around  incident  reporting,  and  the  requirement  to  complete  their 
incident reporting training on the Trusts electronic training platform, ‘Elevate’. Staff who 
were already compliant were directed to complete refresher training on incident reporting 
where required.  

The  Elevate  training  sessions  focus  on  how  to  identify  when  an  incident  should  be 
reported on DCIQ, and how to  robustly complete the incident reports, with a focus on 
how to improve the quality of the record.  

We  are  pleased  to  report  that  as  of  January  2025  Edith  Cavell  Ward  has  100% 
compliance  with  incident  reporting  training.  A  recent  audit  of  the  Trust-wide  position 
shows good compliance with this training, currently 89%. 

Communication has been sent to all our inpatient adult wards raising awareness of what 
action should be taken if they identify a case of line fracture, and details of how to access 
our ‘MSEPO-23026 Central venous access in adults’ (CVAD) policy included for ease of 
reference.  This  policy  provides  detailed  guidance  for  management  of  central  venous 
access lines, and how to manage the line if issues arise. This is a current policy in place, 
accessible to all staff. 

Each month we hold in-person Senior Leader’s briefing sessions on all our acute hospital 
sites. The purpose of these briefings is to share key messages to senior colleagues, and 
the expectation is for these messages to be cascaded to all teams across all trust sites. 

On 7 January 2025, our presentation referenced the anonymised detail of Mr Burrough’s  
case, with a reminder that all staff have a duty to report incidents. It was emphasised that 
this includes where there is a near miss incident or no harm has been caused, and where 
all appropriate immediate actions have been taken.  

Further,  we  specifically  drew  colleagues’  attention  to  the  fact  that  incident  reporting 
includes but is not limited to all equipment failures or breakages, e.g., CVC line ruptures, 
which are reportable to Medicines and Healthcare products Regulatory Agency (MHRA). 

In addition to this, the Patient Safety team issued an ‘MSE Patient Safety update’  during 
the  week  commencing  13th  January  2024,  highlighting  the  importance  of  reporting 
incidents, and our expectations on how the incident record should be managed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Delay in removal of the Hickman line 

(3) Mr Burroughs had a jejunal extension to his PEG on 15 January 2024. Advice 
was  received  that  the  Hickman  Catheter  should  be  removed  as  soon  as 
possible if it was not being used.  

(4) Mr Burroughs was tachycardic and spiked a temperature on 19 January 2024 
with  no  apparent  symptoms  of  recurrent  aspiration  and  the  Hickman  Line 
remained in situ.  

(5) The Hickman Catheter was surgically removed on 30 January 2024.  

Our CVAD policy referred to above was in place at the time of Mr Burroughs’ admission, 
which stipulates the necessity of vascular service input in the removal of indwelling lines.  

I have not attached a full copy of the policy, however the guidance from section 5.15 of 
the MSEPO-23026 Central venous access in adults states: 

‘The removal of a cuffed CVAD/CVC (Hickman) or a Port/tunnelled haemodialysis 
line is a surgical procedure and is to be arranged with the vascular surgeons/renal 
team by the responsible clinician. 
IF YOU THINK THE PORT IS INFECTED – OBTAIN BLOOD CULTURES and DO NOT 
DELAY ESCALATION - THIS SHOULD BE REMOVED WITH 24 HOURS BY THE ON 
CALL VASCULAR SURGEONS due to CRBSI.’ 

We are aware that as soon as the request for removal of Mr Burroughs’ Hickman line 
was escalated to the vascular team at consultant level, the surgery was performed both 
urgently and safely.  

We recognise that Mr Burroughs case identified non-adherence/awareness of the CVAD 
policy by clinicians across specialties, and specifically at the resident surgeon level. We 
have retrospectively raised an incident for the delay in removal of the line so that we can 
identify the issues and take the necessary action to avoid recurrence. 

On 16 January 2025, the Clinical Director for Vascular Services, 
 presented 
Mr Burroughs’ case to the vascular governance team meeting and discussed the need 
to remove in dwelling lines as soon as possible, (within the limitations of theatre access 
and  emergency  case  prioritisation).  Attention  was  drawn  to  the  CVAD  policy  and  the 
importance of compliance to ensure patient safety. 

Communications  have  also  been  sent  to  all  inpatient  adult  wards  reminding  staff  to 
access the CVAD policy reiterating the importance of the timely removal of Hickman lines.  

Further, it is our intention for the concerns raised in this PFDR report to be presented at 
the trust’s next audit day which is attended by staff of all grades to raise awareness of 
the issues and maintain compliance. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 If I can assist further with these matters, please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 
Mid and South Essex NHS Foundation Trust