Recipient

Royal College of Anaesthetists

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First report 11 Jul 2014•Latest report 8 Oct 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Health professional body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
17

Naming this recipient

Published responses
94%

Found for named reports

Concerns addressed
32

Across all linked responses

Stated actions
74

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

94%published responses found
74stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Royal College of Anaesthetists linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Milton Keynes

    AI-generated summary

    William King · 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

    William King died at Milton Keynes University Hospital on 26 January 2025 following an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The principal concerns were inadequate explanation and documentation of the risks and necessity of a nasogastric tube, failure to implement the relevant consent policy, and unclear responsibility for ensuring this aspect of care was addressed.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate explanation of NG tube risks and necessity to patients

    Wider context from the report

    “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document consent discussions about NG tube treatment

    Wider context from the report

    “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement consent policy in practice

    Wider context from the report

    “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of clear responsibility for explaining NG tube necessity

    Wider context from the report

    “i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists. ”
    Open source report

  2. Surrey

    AI-generated summary

    Pamela Anne Marking · 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

    Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners

    Wider context from the report

    “1. The term ‘Physician Associate’ is misleading to the public Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery

    Wider context from the report

    “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this 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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients

    Wider context from the report

    “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of promptly accessible suction for aspiration during rapid sequence induction

    Wider context from the report

    “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform patients and families that Physician Associates are not medically qualified

    Wider context from the report

    “3. The right of patients and family to seek a second opinion The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of public understanding of the Physician Associate role

    Wider context from the report

    “2. Lack of public understanding of the role of Physician Associate Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance on TIVA dosing and timing for rapid sequence induction

    Wider context from the report

    “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4). ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction

    Wider context from the report

    “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prevent Physician Associates undertaking roles outside their competency

    Wider context from the report

    “2. Lack of public understanding of the role of Physician Associate Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regulated scope-of-practice guidance and recognised training for Physician Associates

    Wider context from the report

    “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities. ”
    Open source report

  3. Cambridgeshire and Peterborough

    AI-generated summary

    Rachel Gibson · 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

    Rachel Gibson underwent hip replacement surgery in April 2022 and received an excessive dose of Ropivacaine, after which she suffered an unwitnessed cardiac arrest and irreversible brain damage. She died in hospital on 14 July 2022. The principal concerns were unclear responsibilities for prescribing, checking and administering the local anaesthetic, inconsistent prescription units, and wide variation in similar practices nationally.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Variation in local anaesthetic prescribing practices

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the anaesthetist to verify the nurse’s written local anaesthetic record

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check the drawn-up local anaesthetic with the anaesthetist

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Variation in local anaesthetic administration practices

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear responsibility for administering the local anaesthetic

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Variation in local anaesthetic checking practices

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document the local anaesthetic instruction

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent units in local anaesthetic prescribing

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”
    Open source report

  4. Norfolk

    AI-generated summary

    Derryck Lynn CROCKER · 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

    Derryck Crocker underwent a CT-guided lung biopsy on 3 May 2023 and subsequently developed a cerebral air embolism, deteriorated, and died on 10 May 2023. The principal concerns were limited recognition of air embolism following invasive procedures, insufficient training and awareness across medical specialties, and delays in recognition and treatment that may increase the likelihood of death.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise and report air embolism cases

    Wider context from the report

    “2. I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr Crocker’s death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in recognising air embolism

    Wider context from the report

    “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in treating air embolism

    Wider context from the report

    “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of nationally consistent air embolism awareness training across relevant specialties

    Wider context from the report

    “4. I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge and training on recognising air embolism following invasive procedures

    Wider context from the report

    “1. I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure. I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors. While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly. ”
    Open source report

  5. Avon

    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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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

  6. East London

    AI-generated summary

    Gary David Ash · 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

    Gary David Ash died at Queen's Hospital on 25 June 2019 after developing serotonin syndrome shortly after receiving a general anaesthetic without valid consent. He subsequently received large amounts of intravenous fluid, developed fluid overload and pulmonary oedema, and suffered a cardiac arrest. The principal concerns included knowledge and management of neuroleptic malignant syndrome and serotonin syndrome, use of Dantrolene, fluid monitoring, and potential drug interactions affecting cardiac contractility.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of neuroleptic malignant syndrome management and appropriate Dantrolene use

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of the Dantrolene–Labetalol interaction reducing cardiac contractility

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of serotonin syndrome diagnosis and risk following combined Fentanyl and Ondansetron use

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of Dantrolene-associated pulmonary oedema risk during intravenous fluid overload

    Wider context from the report

    “The Inquest heard evidence from an expert (Professor of Anaesthesia), who has a specialist expertise in adverse drug reactions following anaesthesia and specialist expertise in the conditions of neuroleptic malignant syndrome and malignant hyperthermia. The Professor raised concern, which was reflected in the inquest evidence, in relation to general medical knowledge relating to the following: 1. Management of the condition neuroleptic malignant syndrome, including the inappropriate, off licence, use of Dantrolene. 2. The role of Dantrolene in the development of pulmonary oedema in the presence of intravenous fluid overload. 3. The potential interaction between Dantrolene and Labetalol in relation to the reduction of cardiac contractility. 4. The lack of knowledge around the diagnosis of serotonin syndrome and the risk of it developing following the combined use of Fentanyl and Ondansetron as part of anaesthesia. ”
    Open source report

  7. West Sussex, Brighton and Hove

    AI-generated summary

    David Bryan Moore · 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

    David Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube

    Wider context from the report

    “1. Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube ”
    Open source report

  8. West Yorkshire (Western)

    AI-generated summary

    Maxwell Frame · 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

    Maxwell Frame presented with sepsis caused by a pelvic abscess and bowel obstruction and underwent emergency surgery. A central venous catheter was incorrectly inserted into an artery and was later removed; clot dislodged during removal, causing strokes, after which he received palliative care and died. The report identified concern about the absence of a single national policy for central venous catheter placement.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a national policy on the placement of central venous catheters

    Wider context from the report

    “Absence of a national policy on the placement of CVC’s Over the course of the inquest hearing, oral evidence was provided by several anaesthetic/ ICU doctors ranging from experienced consultants, specialty Dr’s and a Core Trainee 2 all of whom had experience to varying degrees of placing CVC’s. These Dr’s had worked in several hospitals predominantly across the Midlands and North of England. The Trust had a policy entitled Central Venous Access Device which identified the steps that I have identified earlier should have taken place but were not. I was advised by the Dr’s who gave evidence that there was no single standard policy that they had encountered nationally for the placement of CVC’s. The Trust in this case following their internal investigation of Mr Frame’s case had felt it necessary to revise their policy. Further, I was advised by some of the Dr’s who gave evidence that they felt a national policy regarding the placement of CVC’s would be beneficial. ”
    Open source report

  9. East London

    AI-generated summary

    Mrs Surekha Pandharinath Shivalkar · 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

    Mrs Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use targeted factual communication between surgical and anaesthetic teams during surgery

    Wider context from the report

    “2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate a surgeon's reasons for leaving surgery to the surgical team

    Wider context from the report

    “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively monitor when a surgeon leaves theatre

    Wider context from the report

    “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a system to assess the appropriateness of a surgeon leaving surgery

    Wider context from the report

    “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a formal preoperative risk assessment tool requirement

    Wider context from the report

    “1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a 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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record a surgeon's early departure in the surgical notes

    Wider context from the report

    “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
    Open source report

  10. Milton Keynes

    AI-generated summary

    Glenda May Logsdail · 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

    Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inhibitory hierarchical structure preventing staff from speaking up during emergencies

    Wider context from the report

    “(5) There was evidence of an inhibitory hierarchical structure which prevented others shouting out. This is despite the fact that I found Dr ████████ to be a mild mannered, gentle and reflective witness. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness of the capnography safety campaign among anaesthesia staff

    Wider context from the report

    “(1) I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of the Royal College of Anaesthetists campaign video “Capnography in Cardiac Arrest: No Trace = Wrong Place”. (2) I became even more concerned when towards the end of the Inquest when I was hearing evidence on the Incident Investigation Report the author, told me he had not been aware of the campaign himself until this incident. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inappropriate delegation of irrelevant tasks during anaesthetic emergencies

    Wider context from the report

    “(7) The panic and chaos led to an inappropriate delegation of an irrelevant task to a Consultant Anaesthetist who attended to assist who eventually was the one to realise the ET tube was misplaced. This distracted her for a minute or two adding to the time when Mrs Logsdail was not ventilated. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to perform confirmatory checks of endotracheal tube placement

    Wider context from the report

    “(3) As Mrs Logsdail’s condition deteriorated there was no evidence that any confirmatory checks, notably looking for the presence of a capnography trace or expiratory misting, were done to check correct placement of the endo tracheal tube. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reassess possible correctable causes when the patient fails to improve

    Wider context from the report

    “(4) As Mrs Logsdail deteriorated Dr ████████ erroneously fixated on a diagnosis of anaphylaxis being responsible for the collapse. That fixation was contagious and appeared to compromise the assessments by other staff members who attended to help. Dr ████████ did not go back to basics and consider A(airway), B (breathing), C (circulation) to work his way through possible correctable causes. He told me frankly that he became more and more fixated on anaphylaxis as the cause. Despite treatment for anaphylaxis and Mrs Logsdail’s failure to improve he persisted with this as the diagnosis. His certainty in his diagnosis inhibited other staff members from effectively contemplating other causes until the arrival of another Consultant Anaesthetist. I accept entirely that he was not behaving in a dismissive or aggressive manner. He simply conveyed an infectious certainty which hindered other team members challenging him when several could see that Mrs Logsdail was increasingly cyanosed and in desperate straits. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent ventilator display configurations across clinical areas

    Wider context from the report

    “(8) I heard that there were variable and different configurations with respect to the displays on the ventilators in different theatres and anaesthetic rooms and ITU through the hospital. This was confusing for staff and had potential to put patients at risk. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of emergency team leadership, role clarity and coordination

    Wider context from the report

    “(6) There was panic and chaos in the anaesthetic room. There was considerable confusion as to roles and there was an absence of a leader dealing with the emergency. Dr ████████ was the natural leader but I found that he was effectively blind to what needed to be done – to check the capnograph and to reintubate. Individual staff members took on roles independently in the cardiac arrest. That is to be commended on an individual level but it betrays a fundamental lack of direction and control of the situation and bodes poorly for management of future life threatening emergencies. The team malfunctioned and did not operate as a team. ”
    Open source report

  11. East London

    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.

    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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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

  12. Inner North London

    AI-generated summary

    Mike Fell · 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

    Mike Fell underwent elective abdominal aortic aneurysm repair and later suffered cardiac arrest after a trauma-line 3-way tap was found to be open to air. He sustained a cerebral air embolism and intracerebral bleed, and died in hospital in the early hours of 27 October 2017. Concerns included the absence of recorded checks that unused taps were closed to air and the lack of a clamp on the trauma lines.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of clamps to close unused trauma lines

    Wider context from the report

    “(2) The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record checks that unused taps are closed to air

    Wider context from the report

    “(1) Whilst it is a matter of routine care to check that unused taps are “closed to air”, it is not recorded in Mr Fell’s notes that the taps had been checked and were closed. It is unclear how or when the 3-way tap on the trauma line became “open to air” ”
    Open source report

  13. Cambridgeshire and Peterborough

    AI-generated summary

    Peter Saint · 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

    Peter Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists

    Wider context from the report

    “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients

    Wider context from the report

    “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure utilisation of capnography by clinical staff who may intubate patients

    Wider context from the report

    “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to observe capnography for up to 15 to 20 seconds after intubation

    Wider context from the report

    “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial. ”
    Open source report

  14. Northamptonshire

    AI-generated summary

    Mrs Macrae · 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

    Mrs Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek attendance by the attending spinal surgeon for postoperative instability

    Wider context from the report

    “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery

    Wider context from the report

    “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”
    Open source report

  15. London Inner (South)

    AI-generated summary

    Ololade Olaobaju · 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

    Ololade Olaobaju was treated for progressive respiratory failure following community-acquired pneumonia and was transferred to intensive care for mechanical ventilation. After unsuccessful attempts at intubation, needle cricothyroidotomy and “Quicktrack”, she suffered a cardiac arrest during an attempted surgical tracheostomy and could not be resuscitated. The report identified a concern that existing guidance did not cover the preferred front-of-neck access when anaesthetists and ENT surgeons were both present, particularly in a rapidly deteriorating “Can’t Intubate Can’t Oxygenate” situation.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of joint guidance for front-of-neck access during a “Can’t Intubate Can’t Oxygenate” emergency involving anaesthetists and ENT surgeons

    Wider context from the report

    “(1) For the purposes of the inquest I received an expert report from Dr Andrew Hartle. Reference was also made to the Difficult Airway Society Guidelines 2004 and 2015. The DAS guidelines suggest that, for an anaesthetist, an appropriate progression would be to undertake surgical (scalpel) cricothyroidotomy after unsuccessful cannula cricothyroidotomy. In this case, an ENT surgeon (clinical fellow grade) arrived and took over before scalpel cricothyroidotomy was attempted. The ENT surgeon decided to attempt tracheostomy rather than scalpel cricothyroidotomy. The benefit of tracheostomy is that it would have provided a more permanent airway. The evidence was that this is an unusual situation and that the experience of all the witnesses was therefore limited in performing emergency cricothyroidotomy and emergency tracheostomy. I concluded that the decision as to whether to opt for tracheostomy or scalpel cricothyroidotomy was a clinical judgment made in the light of the circumstances at the time. However, this was rapidly deteriorating situation and the ENT surgeon accepted that scalpel cricothyroidotomy may have been a simpler procedure. This became a “Can’t Intubate Can’t Oxygenate” situation in which both anaesthetists and ENT surgeons were present. My understanding is that the DAS guidelines are provided for anaesthetists. Different considerations may apply to ENT surgeons. The question as to the preferred mode of front of neck access in this situation therefore appears not to be covered by the existing guidelines. Individual practitioners faced with such a situation are likely to have limited experience. My understanding is that there is currently no joint guidance to cover this type of situation when both anaesthetists and ENT surgeons are present. ”
    Open source report

  16. Avon

    AI-generated summary

    Gerald Trevor WERRETT · 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

    Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.

    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to examine patients prior to chest drain insertion

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Incorrect interpretation of the cardiac silhouette

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Misinterpretation of chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use a lead anatomical marker when taking chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure by clinicians to identify incorrectly labelled chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider both chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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 Royal College of Anaesthetists; that does not assign responsibility.

    PFD Monitor interpretation

    Incorrect labelling of chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”
    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

    Work with colleagues to identify, learn from and share lessons from the chest-drain incident.

    Verbatim wording from the response

    “General aspects - The College was alerted to a specific chest drain insertion problem earlier this year which led to notification to our safety network in March 2014. The initial notification and subsequent alert were completely anonymised; however, from the detail you have provided we now believe this was the same incident you now highlight and our ongoing work with colleagues will focus on lessons to be learned and shared from this situation.”

    Source location

    2014-0355-Response-by-The-Royal-College-of-Anaesthetists
    Page 2 · response
    Published 1 August 2014

    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

    Responsibility for reviewing and potentially reissuing the chest-drain safety alert lies with NHS England’s safety department.

    Verbatim wording from the response

    “You would wish to be aware of an alert issued by the National Patient Safety Agency (NPSA) in May 2008 regarding chest drains (http://www.nrls.npsa.nhs.uk/resources/?EntryId=45987) and this is still a key point of reference for anaesthetists and others in their safe use. Despite the closure of the NPSA we believe the responsibility for these alerts continues through the safety department within NHS England and we have advised them of this death, with anonymised detail, and requested they review the alert and consider its re-issue.”

    Source location

    2014-0355-Response-by-The-Royal-College-of-Anaesthetists
    Page 2 · response
    Published 1 August 2014

    Open published response

  17. Surrey

    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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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 Royal College of Anaesthetists; 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
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

94%
94%All other recipients 58%
0%100%

How actions were described at the time

This respondent
24%18%57%1%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026