Colin Foley

Professor Paul Marks  
Senior Coroner for City of Kingston Upon Hull 
and the County of the East Riding of Yorkshire 
Coroner’s Service 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

8th May 2026 

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 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 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: 

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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.  

Yours sincerely,  

National Director of Patient Safety  

NHS England