14 Mar 2025 Dominic Martin PHILIP · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Lack of pre-injection identification of potential allergy to iodinated contrast agents View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Dominic Martin PHILIP · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of pre-injection identification of potential allergy to iodinated contrast agents
Wider context from the report “a) It was stated in evidence that - an X-Ray is no longer preferred as it is not sensitive enough and a smaller obstruction might be missed; anaphylactic type reactions to iodinated contrast agents are rare accounting for 0.6% of cases with only 0.04% considered aggressive; and almost all contrast reactions that are life threatening occur within 20 minutes of intravenous injection. The current policy appears to be that a patient referred for a CT scan by the Emergency Department is to be accompanied by a doctor trained in advanced life support (ALS). In Mr Philip’s case, he was accompanied by a Core Trainee Year 2 who had ALS training. The policy for planned/outpatient interventions was not fully explored at inquest, but there was a suggestion that there might be some possibility testing for an allergic reaction to the contrast medium in advance of such an appointment? My concern is that if a patient has never before had contrast medium (as was the case with Mr Philip) they cannot possibly know if they have an allergy to it . Making arrangements for ALS after the event seems reactionary and I wondered if any other options might be available which would flag a potential allergy before the contrast is injected .
” Source location Dominic Martin PHILIP · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish guidance on administering iodinated contrast media and gadolinium through the established working party.
Verbatim wording from the response “There are several different manufacturers of iso-osmolar iodinated contrast medium (ICM) which is typically used when a CT scan is performed. For a number of years the UK radiology community has looked to the European Society of Urogenital Radiology and the Royal Australian and New Zealand College of Radiologists guidelines on the use of such ICM. The RCR has recently established a working party to develop ICM guidance that will provide recommendations on the administration of iodinated ICM and gadolinium. We anticipate this guidance will be published in early 2026.” Source location Response from The Royal College of Radiologists
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No reliable standardised test can currently predict contrast reactions in patients without prior adverse symptoms.
Verbatim wording from the response “It should further be noted that there is currently no reliable or standardised test to predict patients that may have a reaction to contrast without any history of adverse symptoms.” Source location Response from University Hospitals of Northamptonshire NHS Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine allergy testing is not viable because services lack capacity and testing could delay diagnostic and cancer-treatment pathways.
Verbatim wording from the response “This immunology testing is not available at either of the hospitals within the University Hospitals of Northamptonshire (UHN) and patients would need to be referred to tertiary centres such as Leicester, Oxford or Addenbrooke’s to obtain this test. This process would have a potential significant impact on patients in the Northamptonshire area in terms of time, travel and cost.” Source location Response from University Hospitals of Northamptonshire NHS Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine pre-exposure allergy testing for iodinated contrast medium is not considered necessary because reactions are rare and testing could delay urgent CT scans.
Verbatim wording from the response “Regarding drug allergies, it is an inherent characteristic of all medications that a patient may not be aware of an allergy until they are exposed to the drug. Given the very low incidence of allergic reactions, routine pre-exposure testing for all patients is not standard medical practice for most medications and ICM has a lower incidence of provoking an anaphylactoid reaction than many other medications which are similarly not assessed.” Source location Response from The Royal College of Radiologists
Open published response
6 Nov 2020 Stanley Alfred Babbs · Prevention of Future Deaths report East London
View report summary
Concerns raised 4
Failure to identify a responsible clinician for contrast administration View source Administration of contrast media without a formal prescription View source Lack of careful consideration of contrast medium dose View source
Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury View source See 1 more concern
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Barking, Havering and Redbridge University Hospitals NHS Trust
Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Obtain approval for radiographer PGDs and update the internal protocol to permit contrast injection on a radiologist’s prescription for eGFR 30–45.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Require an ED clinician’s prescription for intravenous contrast for specified direct-access scans, recording it in the notes and RIS as an interim measure.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Specify contrast dosing at 1 ml/kg up to a 100 ml maximum.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Provide medical scales for all scanners to support the specified contrast dosing.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
View source See 5 more actions
×
AI-generated summary
Stanley Alfred Babbs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify a responsible clinician for contrast administration
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it .
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Administration of contrast media without a formal prescription
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast . This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription , evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of careful consideration of contrast medium dose
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight .
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain approval for radiographer PGDs and update the internal protocol to permit contrast injection on a radiologist’s prescription for eGFR 30–45.
Verbatim wording from the response “• Practice Group Direction (“PGD”) approval for Radiographers/updating internal protocol to enable Radiographers to inject IV contrast on a Radiologist’s prescription, for patients with eGFR between 30 and 45” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require an ED clinician’s prescription for intravenous contrast for specified direct-access scans, recording it in the notes and RIS as an interim measure.
Verbatim wording from the response “• Scans on direct access pathway from ED which need contrast e.g. CT Angiogram for stroke will require a prescription for contrast in the patients notes. (As per action 9 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
Verbatim wording from the response “• Prescriptions for CT IV contrast for patients with eGFR < 30 to ensure these requests are appropriately authorised. (As per action 4 on Plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specify contrast dosing at 1 ml/kg up to a 100 ml maximum.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medical scales for all scanners to support the specified contrast dosing.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
Verbatim wording from the response “• Creating a new Radiology request form to incorporate safeguards for patients with abnormal renal function and to confirm that the clinician has indicated the use of contrast and if a discussion has taken place with the patient about the use of contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
15 Dec 2015 Joyce Beatrice TOZER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Administration of hypertonic Omnipaque through central lines View source Frequent administration of Omnipaque doses exceeding manufacturer guidelines View source
×
AI-generated summary
Joyce Beatrice TOZER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joyce Beatrice Tozer died after her condition deteriorated dramatically and she suffered cardiac arrest minutes after receiving 100ml of Omnipaque through a central line during an interventional radiology procedure to insert bilateral nephrostomies. The inquest concluded that she died from a reaction to the contrast material, but it could not determine whether this was an allergic response or toxicity. Concern was raised that doses exceeding the manufacturer’s guidance were frequently administered, sometimes through central lines, potentially exposing patients to toxicity risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Administration of hypertonic Omnipaque through central lines
Wider context from the report “(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access . At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used. I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered, sometimes through central lines , and this practice could be exposing interventional radiology patients to risks from toxicity.
” Source location Joyce Beatrice TOZER · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Frequent administration of Omnipaque doses exceeding manufacturer guidelines
Wider context from the report “(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access. At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used . I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered , sometimes through central lines, and this practice could be exposing interventional radiology patients to risks from toxicity.
” Source location Joyce Beatrice TOZER · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.
Verbatim wording from the response “A round table meeting was held on 24th December to discuss whether an overdose was a causative factor in the death of the deceased. The roundtable review noted that the deceased had become unwell following administration of 100ml Visipaque (Omnipaque was incorrectly documented in the medical notes, the correct contrast agent is recorded on the Trust’s imaging system. 100mls is considered to be a standard dose; Visipaque is iso-osmolar and therefore theoretically less toxic than Omnipaque).” Source location Joyce-Tozer-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.
Verbatim wording from the response “1. The radiographer administering the contrast acted entirely appropriately and within the limitations of the expanded practice IV protocol;” Source location Joyce-Tozer-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.