Dear Mr Pollard Colin Garth Deceased Regulation 28 Report to Prevent Future Deaths am writing in response to your Regulation 28 Report issued following the Inquest into the death of Colin Garth which concluded on 20 October 2016. May take this opportunity to extend my sincere condolences to the family of Mr Garth for their loss_ am now in a position to respond to your concerns as outlined in Section 5 of your report as follows: Section 5 (A) am sorry to learn that during the course of establishing how Mr Garth came about his death you heard evidence that when patients with a Hickman or other central Iine in situ are discharged from hospital are not provided with any guidance booklet or information sheet as to the aforementioned line should be looked after. would like to assure you that all our patients with central lines in situ; who are looked after by the oncology and haematology teams are provided with an information leaflet created by Macmillan Cancer Support. This provides an explanation as to what the is , how t0 care for it in addition to identifying any potential problems with the line. However; as this leaflet contains the Macmillan logo, it is not appropriate to provide the same leaflet to our patients who have central lines in situ but are not oncology or haematology patients As such, a new generic leaflet is being developed, based on the Macmillan leaflet and expect this will be available to all patients with central lines following completion of the Trust's internal approval process by the end February 2017 . they how line

Section 5 (B) was disappointed to learn that despite the Trust having a clear Policy relating to the use of central lines, and in particular where a line infection is suspected, that staff demonstrated a lack of knowledge around this As a result of this the Governance Leads and Practice Educators for each of the Divisions within the Trust are embarking on a programme of continuous education for all clinical staff which will include raising the awareness of the Policy in addition to the overall management of central lines_ As part of this process, the Deputy Director of Infection Control is currently reviewing the Policy in order to provide further clarity on the management of Iine infections The amended Policy is due to be approved at the next Infection Control Committee in January 2017 . Section 5 (C) Again, was extremely disappointed to hear that a member of staff continued to use a piece of medical equipment when a fault should have been identified which should have resulted in the equipment taken out of use immediately The Trust has a very clear Medical Devices and Equipment Policy which describes in detail what action staff should take when using medical devices; In particular, Section 9(1) describes the responsibility of staff to report faults relating to medical devices via the Trust incident reporting process and furthermore, Section 10 (1) deals with the responsibilities of the user of the medical equipment to ensure that it has been checked to use and damaged equipment is not used for patient care would like to assure you that we are currently engaged in a Trust wide programme of training relating to management of medical equipment which incorporates actions we expect staff to take when equipment is faulty or there is a suspicion of a fault: The Divisional Governance Leads report progress on this training on a quarterly basis to the Clinical Governance and Quality Committee who will retain overall scrutiny on progress. hope that my response detailed above has provided you with assurance that the Trust has the necessary systems and processes in place to ensure that all members of staff continue to be aware of the management of central lines in addition to the appropriate management of medical equipment: Please do not hesitate to contact me in the event you require any further assistance