FOI release

retained plastic stiffener in a pigtail drain

Case reference FOI2025/01022

Received 19 September 2025

Published 24 October 2025

Request

A colleague inadvertently recently left a plastic stiffener within a pigtail drain at thereby reducing its lumen and resulting in reduced drainage. In this instance the drain in question was an internal external biliary drain made by Cook medical G09498 ULT10.2-38-40-P-32S-CLB-RH 10.2 .038 40 but the same or similar configuration of plastic stiffener is common to other manufacturers. This is being treated as a Never Event by my hospital but I think there is a common system failure here. Unfortunately in this case the drainage bag was connected to the Luer lock of the hub of the plastic stiffener rather than to the hub of the drain itself. This reduced the lumen diameter and resulted in ineffective drainage. I recall this same error occurring more than 10 years ago. At some point after this Cook placed a paper label on the plastic stiffener stating "remove after catheter insertion" but this can become separated especially if the catheter becomes wet or it can be removed without the operator's knowledge by a scrub assistant. I note that a similar plastic stiffener with a Luer lock is present with the BARD Navarre universal drainage catheter eg. NNU8LPT but, in this case, with no warning label . By contrast the Boston Scientific Flexima APDL locking pigtail drain eg M001 271390 has a plastic stiffener but without a Luer lock hub thus making it impossible to connect a drainage bag with the stiffener still in situ. Perhaps this could be consider to be the universal standard? I would like to know how often this scenario has been reported to you over the next 10 years. I would also like to know whether you would consider reviewing this matter in terms of there being a system vulnerability.

Response

See attached

Documents

• FOI2025_01022 (redacted).pdf (1.1 MB)

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