11 Feb 2026 Chloe Angela Ulett · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion View source Lack of guidance on referral pathways for raised ammonia levels View source Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated View source Failure to consider ammonia testing nationally, causing risk of delayed diagnosis View source Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion View source Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors View source Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients View source Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders View source Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chloe Angela Ulett · 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
Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on referral pathways for raised ammonia levels
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised . The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated . Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to consider ammonia testing nationally, causing risk of delayed diagnosis
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period.
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion
Wider context from the report “1. The window of opportunity to consider and make a diagnosis of a metabolic disorder and institute effective treatment is very short, 24 to 48 hours from the commencement of symptoms , and relies on early measurement of ammonia in an adult presenting with behavioural change and confusion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1 , and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients .
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period .
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department .
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Highlight this case and related ammonia-testing learning, resources, and prior Regulation 28 findings in the tri-annual Safety Bulletin.
Verbatim wording from the response “In order to raise awareness, we will highlight this case in our tri-annual Safety Bulletin. The Safety Bulletin is sent to all Fellows and Members of the Faculty of Intensive Care Medicine, and is a mechanism for promoting learning, with the aim of reducing risk. Through the Safety Bulletin, we will signpost open access resources for and will also highlight the utility of testing ammonia levels in encephalopathy of unknown cause.” Source location 2026-0086 - Response from Faculty of Intensive Care Medicine
Open published response
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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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 Consult on GPICS version 3 guidance, including standards for echocardiography access, image storage, training and quality assurance.
Verbatim wording from the response “Together with the Intensive Care Society, the Faculty publishes the Guideline for the Provision of Intensive Care Services (GPICS). Over the last decade, GPICS has become the definitive reference for planning, commissioning and delivery of adult intensive care services in the UK. GPICS version 3 is currently at the consultation stage. In the chapter of GPICS version 3 titled ‘Cardiovascular Support’, it is noted that:” Source location Response from Faculty of Intensive Care Medicine
Open published response
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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 Review HiLLO descriptors and consider clarifying echocardiography training and skills requirements.
Verbatim wording from the response “The most recent curriculum for doctors training in intensive care medicine was implemented in 2021. As with all postgraduate medical training curricula it meets, and is informed by, the requirements mandated by the General Medical Council (GMC). One requirement is that a specific course or accreditation cannot be specified. Instead, the GMC has asked that training curricula are modelled to describe a number of high-level capabilities (so called ‘High Level Learning Outcomes, or HiLLOs). The curriculum for intensive care medicine contains fourteen HiLLOs. The use of focused echocardiography is covered in HiLLO 6:” Source location Response from Faculty of Intensive Care Medicine
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 Work with hospital cardiology service providers to improve reliable access to emergent out-of-hours echocardiography.
Verbatim wording from the response ““Whilst current guidelines recommend that hospitals who admit acute cardiology patients have access to echocardiography 24/7, this may not be universally available. Intensive care physicians have an important role in improving access to echocardiography out-of-hours to support / exclude the diagnosis of cardiac pathologies. This will ultimately facilitate triage. The sickest patients need to undergo emergent echocardiography by someone trained to British Society of Echocardiography (BSE) level 1 standard or higher.”” Source location Response from Faculty of Intensive Care Medicine
Open published response
13 Jun 2024 Joseph Lawrence Parker · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to endorse and disseminate PUMA airway management guidance View source Lack of changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph Lawrence Parker · 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
Joseph Lawrence Parker took an overdose of medication on 17 February 2022, collapsed, and was taken to Southmead Hospital for intubation. The breathing tube was accidentally positioned in the oesophagus and the misplacement was not identified promptly, contributing to cardiac arrest, hypoxic encephalopathy, and his death on 16 April 2022. The principal concerns relate to recognising incorrect tube placement, the use and interpretation of capnography, and the dissemination of relevant airway-management guidance.
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. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to endorse and disseminate PUMA airway management guidance
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” Open source report
Concerns raised 1 Failure to share nationally the risks associated with medication use in patients at risk of serotonin syndrome View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Katie Anne WILLIAMS · 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
Katie Anne WILLIAMS took an intentional overdose of prescribed medication and was admitted to intensive care with severe complications, including aspiration pneumonia and paralytic ileus. She died at Derriford Hospital on 24 May 2021 after developing fatal serotonin toxicity associated with delayed absorption of the overdose and the subsequent administration of a sedative drug. The principal concern was that similar risks may not be fully appreciated by other NHS organisations in comparable cases.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to share nationally the risks associated with medication use in patients at risk of serotonin syndrome
Wider context from the report “The administration of ████████ from day four of Katie's hospital admission reprecipitated her serotonin syndrome and directly contributed to her death. The Trust has recognised this and amended its sedation policy to recommend "lower risk" opiates (such as morphine) are used in patients who have taken overdoses of medications where there is a risk of serotonin syndrome / toxicity.
It is accepted that the way the ████████ interacted in this case was unexpected, and appears to have occurred due to the particular circumstances of Katie's case; in particular an aspiration pneumonia requiring treatment in the prone position, and the development of a paralytic ileus. However, these complications are not unusual in patients who have taken overdoses of these types of medications and as such I consider there is a risk a future death may occur in similar circumstances.
I am concerned that other NHS organisations may not fully appreciate the risks associated with the use of ████████ in patients such as Katie and that this information should be shared with those organisations on a national level .
” Open source report
7 Jul 2021 Mr Kishorkumar Patel and Mr Kofi Aning · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Insufficient ICU staff knowledge of breathing system filter and HME selection View source Lack of standardised classification and colour coding of breathing system filters and HMEs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Kishorkumar Patel and Mr Kofi Aning · 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
Mr Kishorkumar Patel and Mr Kofi Aning were treated at the Nightingale Hospital in London in April 2021, where the wrong filter was found to have been used in the breathing systems of their intensive care ventilators. The principal concern was widespread confusion among intensive care staff about filter types, names, colour coding, positioning and use in wet or dry breathing systems, with the expert recommending review, simplification and standardisation; causation of the deaths had not been determined.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient ICU staff knowledge of breathing system filter and HME selection
Wider context from the report “An independent expert has advised:
In my opinion, the non-standardised colour coding used by manufacturers of these filters, the number of different types of filters with different names, the variable optimal position of the filters, and whether a wet or a dry breathing system is being used, results in an extremely confusing situation. One of the leading manufacturers of these filters (Intersurgical) produces HME's that are blue, which is the same colour as the non-HME filters supplied to NHS by another company. A photograph of the non-HME blue filter is inconsistent with the photograph of the green HME and yellow non HME's shown on page 6 of the guidance for use of anaesthetic machines for the ventilation of adult critical care patients. In my experience, few doctors and nurses working in ICU are knowledgeable about all these different filters and which ones should be used for any given breathing system.
In my opinion, the confusion over breathing system filters and HMEs is widespread among ICU staff (doctors and nurses) and the classification and colour coding of these filters/HMEs is worthy of review, simplification, and standardisation.
The concerns raised by the independent expert are not confined to the Nightingale, emergency provision hospitals, but relate equally to all intensive care settings, particularly when the intensive care provision has to be extended to other areas of the hospital.
As there are still pressures within the ITU settings and in light of the imminent, planned reduction in COVID-19 safeguards, I consider that action should be taken to address this concern at the earliest possible stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised classification and colour coding of breathing system filters and HMEs
Wider context from the report “An independent expert has advised:
In my opinion, the non-standardised colour coding used by manufacturers of these filters, the number of different types of filters with different names, the variable optimal position of the filters, and whether a wet or a dry breathing system is being used, results in an extremely confusing situation . One of the leading manufacturers of these filters (Intersurgical) produces HME's that are blue, which is the same colour as the non-HME filters supplied to NHS by another company. A photograph of the non-HME blue filter is inconsistent with the photograph of the green HME and yellow non HME's shown on page 6 of the guidance for use of anaesthetic machines for the ventilation of adult critical care patients. In my experience, few doctors and nurses working in ICU are knowledgeable about all these different filters and which ones should be used for any given breathing system.
In my opinion, the confusion over breathing system filters and HMEs is widespread among ICU staff (doctors and nurses) and the classification and colour coding of these filters/HMEs is worthy of review, simplification, and standardisation.
The concerns raised by the independent expert are not confined to the Nightingale, emergency provision hospitals, but relate equally to all intensive care settings, particularly when the intensive care provision has to be extended to other areas of the hospital.
As there are still pressures within the ITU settings and in light of the imminent, planned reduction in COVID-19 safeguards, I consider that action should be taken to address this concern at the earliest possible stage.
” 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 Refer standardised breathing-filter labelling and colour-coding to the MHRA for consideration.
Verbatim wording from the response “We confirm our support for standardisation of labelling/colour coding of breathing circuit filters and heat and moisture exchange filters (HMEF) between manufacturers. We highlight that it is not within our power to implement beyond referring the issue to the Medicines and Healthcare products Regulatory Agency to consider whilst recognising the challenges in implementing such a change.” Source location 2021-0233-Response-from-Royal-College-of-Anaesthetists-and-The-Faculty-of-Intensive-Care-Medicine.pdf
Open published response
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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 Highlight key breathing-filter safety lessons to members through the Patient Safety Update and FICM Safety Bulletin.
Verbatim wording from the response “We can confirm that the key lessons will be highlighted to our respective membership through the Safe Anaesthesia Liaison Group’s Patient Safety Update and FICM Safety Bulletin. These will include:” Source location 2021-0233-Response-from-Royal-College-of-Anaesthetists-and-The-Faculty-of-Intensive-Care-Medicine.pdf
Open published response
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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 Implementing standardised breathing circuit filter labelling is outside the respondent’s power.
Verbatim wording from the response “We confirm our support for standardisation of labelling/colour coding of breathing circuit filters and heat and moisture exchange filters (HMEF) between manufacturers. We highlight that it is not within our power to implement beyond referring the issue to the Medicines and Healthcare products Regulatory Agency to consider whilst recognising the challenges in implementing such a change.” Source location 2021-0233-Response-from-Royal-College-of-Anaesthetists-and-The-Faculty-of-Intensive-Care-Medicine.pdf
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 Medicines and Healthcare products Regulatory Agency was referred the issue for consideration of standardised breathing circuit filter labelling.
Verbatim wording from the response “We confirm our support for standardisation of labelling/colour coding of breathing circuit filters and heat and moisture exchange filters (HMEF) between manufacturers. We highlight that it is not within our power to implement beyond referring the issue to the Medicines and Healthcare products Regulatory Agency to consider whilst recognising the challenges in implementing such a change.” Source location 2021-0233-Response-from-Royal-College-of-Anaesthetists-and-The-Faculty-of-Intensive-Care-Medicine.pdf
Open published response
11 Jul 2014 Maria De Oliveria Alva LOPES · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 19 Lack of daily creatine kinase monitoring during propofol infusions View source Lack of national understanding and acceptance of safe propofol amounts View source Lack of consultant ward rounds in weekend urology on-call arrangements View source Delays in urology review of emergency admissions View source Failure to act on or escalate elevated Early Warning Scores View source Undue reliance on outdated admission blood tests for clinical assessment View source Failure to create and adhere to guidelines or protocols for propofol use View source Lack of active management to expedite physician review and ITU admission View source Failure to recognise and treat sepsis in accordance with national guidelines View source Lack of continual assessment for complications of propofol-related infusion syndrome View source Lack of clarity about propofol infusion duration, volume and dose View source Inadequate assessment of renal stone size and hydronephrosis View source Lack of a protocol for propofol use in ITU View source Inadequate supervision of out-of-hours urology trainees View source Lack of medical supervision and control of propofol use in ITU View source Lack of knowledge or implementation of published on-call national guidelines View source Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation View source Lack of understanding of atypical adult presentation of propofol-related infusion syndrome View source Failure of critical care outreach to recognise and escalate concerns of sepsis View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maria De Oliveria Alva LOPES · 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
Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.
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. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of daily creatine kinase monitoring during propofol infusions
Wider context from the report “12. Consideration for the use of daily Creatine Kinase levels when propofol infusions are given
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of national understanding and acceptance of safe propofol amounts
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant ward rounds in weekend urology on-call arrangements
Wider context from the report “1. The consultant urologist’s on call arrangements covering three hospitals at the weekend has no provision for consultant ward rounds , in contravention of suggested national guidelines
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in urology review of emergency admissions
Wider context from the report “4. The review of emergency admissions by urology (not on day of admission, once daily )
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to act on or escalate elevated Early Warning Scores
Wider context from the report “9. Failure to act on or escalate elevated Early Warning Scores as per hospital protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Undue reliance on outdated admission blood tests for clinical assessment
Wider context from the report “6. The assessment and size of the renal stone and hydronephrosis, and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs Lopes’s condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to create and adhere to guidelines or protocols for propofol use
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of active management to expedite physician review and ITU admission
Wider context from the report “7. The lack of active management to expedite physician’s review and to facilitate admission to ITU
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and treat sepsis in accordance with national guidelines
Wider context from the report “5. The recognition and treatment of sepsis as per national guidelines
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of continual assessment for complications of propofol-related infusion syndrome
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about propofol infusion duration, volume and dose
Wider context from the report “10. Lack of clarity to the length, volume and dose of propofol infusion to be given in ITU
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of renal stone size and hydronephrosis
Wider context from the report “6. The assessment and size of the renal stone and hydronephrosis , and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs Lopes’s condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for propofol use in ITU
Wider context from the report “11. Lack of medical supervision and control of the use of propofol in ITU (no protocol in place )
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of out-of-hours urology trainees
Wider context from the report “3. The overall supervision of out of hours urology trainees within the current system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of medical supervision and control of propofol use in ITU
Wider context from the report “11. Lack of medical supervision and control of the use of propofol in ITU (no protocol in place)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge or implementation of published on-call national guidelines
Wider context from the report “2. A general lack of knowledge or implementation of published ‘on call’ national guidelines
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation
Wider context from the report “13. Lack of understanding and acceptance Propofol related infusion syndrome (PRIS) is an accepted albeit rare, complication of the use of prolonged propofol for sedation in Intensive Care Units
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of atypical adult presentation of propofol-related infusion syndrome
Wider context from the report “14. Lack of understanding that PRIS may have an atypical presentation in adults and should always be a consideration when propofol is used for a protracted period of time
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of critical care outreach to recognise and escalate concerns of sepsis
Wider context from the report “8. Failure to recognise and therefore escalate concerns of sepsis by critical care outreach team
” Open source report
29 Apr 2014 Joanne Elizabeth Oliver · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Lack of an appropriate written risk-assessment framework for transferring critically ill patients View source Lack of detailed guidance for decisions about transferring critically ill patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joanne Elizabeth Oliver · 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
Joanne Elizabeth Oliver, aged 31, was transferred by air ambulance after treatment for H1N1 influenza and ECMO, but her condition deteriorated after arrival at Manchester Royal Infirmary. She developed severe metabolic acidosis with high carbon dioxide and potassium levels, suffered cardiac arrest, and died. The report identified an unacceptable delay in obtaining blood gas analysis and monitoring, and raised concerns about the lack of detailed guidance and risk assessment for transferring critically ill patients.
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. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate written risk-assessment framework for transferring critically ill patients
Wider context from the report “(1) Evidence was given that there is no detailed guidance from the Department of Health or the Intensive Care Society to assist in the decision to transfer a critically ill patient. Some guidance is given in a document “Guidelines for the transport of the critically ill adult (2011)” but that is focused on the actual transfer of the patient and not the decision whether to transfer or not, or when this should take place.
(2) It would be of assistance to doctors making the decision to transfer, and would help them to justify the transfer if it was later questioned, if Guidelines could be given to assist in the preparation of a written risk assessment . The evidence was that the “MEWS Score system”, now the “NEW Score system” was never designed with critically ill patients in mind .
(3) Any risk assessment would need to consider:
(a) The multitude of background clinical factors that indicate whether the patient was fit to travel
(b) The practical tests that should be undertaken to confirm fitness for transfer eg trial of transport ventilator, assessment of biochemical stability when renal replacement therapy is withheld
(c) The seniority of the doctors who make that decision, and the numbers of doctors to be involved
(d) Whether it is in the best interest of the patient to make the transfer
(e) The pressures for beds where there is, as in this case, an epidemic forcing doctors to make difficult decisions on the priority of patients.
(f) The danger that a patient is moved out to allow another one in when the first patient is not fully in a state to be moved.
(g) The risk that the doctor responsible for supervising and travelling with the patient may be pressured into agreeing to the transfer
(h) The distance and time of the journey
(i) The risks of deterioration during that journey time
(j) Whether there are risks that the journey time will be extended
(k) Whether it is by road or air, and any factors that arise from the mode of transport
(l) The equipment and medication available during the transfer
(m) The medical staff to accompany the patient and their skills in transferring patients
(n) The actions to be taken by the transferring or receiving doctors on receipt of the patient to confirm their stability after transfer, and the timeframe within which this should be undertaken
(o) The information that should be given to patients or their next of kin prior to transfer such that they too are aware of the rationale for transfer and the intrinsic risks
(p) The standards of documentation for the decision-making in these circumstances and in the above domains
(q) Audit of outcomes of patient transfers (acknowledging that outcomes will not necessarily be collated for those patients deemed unsuitable for transfer for whatever reason)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Faculty of Intensive Care Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed guidance for decisions about transferring critically ill patients
Wider context from the report “(1) Evidence was given that there is no detailed guidance from the Department of Health or the Intensive Care Society to assist in the decision to transfer a critically ill patient . Some guidance is given in a document “Guidelines for the transport of the critically ill adult (2011)” but that is focused on the actual transfer of the patient and not the decision whether to transfer or not, or when this should take place .
(2) It would be of assistance to doctors making the decision to transfer, and would help them to justify the transfer if it was later questioned, if Guidelines could be given to assist in the preparation of a written risk assessment. The evidence was that the “MEWS Score system”, now the “NEW Score system” was never designed with critically ill patients in mind.
(3) Any risk assessment would need to consider:
(a) The multitude of background clinical factors that indicate whether the patient was fit to travel
(b) The practical tests that should be undertaken to confirm fitness for transfer eg trial of transport ventilator, assessment of biochemical stability when renal replacement therapy is withheld
(c) The seniority of the doctors who make that decision, and the numbers of doctors to be involved
(d) Whether it is in the best interest of the patient to make the transfer
(e) The pressures for beds where there is, as in this case, an epidemic forcing doctors to make difficult decisions on the priority of patients.
(f) The danger that a patient is moved out to allow another one in when the first patient is not fully in a state to be moved.
(g) The risk that the doctor responsible for supervising and travelling with the patient may be pressured into agreeing to the transfer
(h) The distance and time of the journey
(i) The risks of deterioration during that journey time
(j) Whether there are risks that the journey time will be extended
(k) Whether it is by road or air, and any factors that arise from the mode of transport
(l) The equipment and medication available during the transfer
(m) The medical staff to accompany the patient and their skills in transferring patients
(n) The actions to be taken by the transferring or receiving doctors on receipt of the patient to confirm their stability after transfer, and the timeframe within which this should be undertaken
(o) The information that should be given to patients or their next of kin prior to transfer such that they too are aware of the rationale for transfer and the intrinsic risks
(p) The standards of documentation for the decision-making in these circumstances and in the above domains
(q) Audit of outcomes of patient transfers (acknowledging that outcomes will not necessarily be collated for those patients deemed unsuitable for transfer for whatever reason)
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations