Concerns raised 23 Minimal respiratory consultant documentation View source Outdated chest drain management protocol lacking complication actions View source Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence View source Excessive patient caseloads and unclear experience among senior resident medical staff View source Failure to document clinical examination View source Failure to complete consent detailing chest drain complications View source Failure to request repeat inflammatory markers View source Poor communication of the post-procedure care plan to ward staff View source Failure to use a WHO checklist for radiological interventions View source Proactive chest drain insertion without objective clinical evidence View source Absence of a documented management plan View source Failure to use real-time ultrasound guidance for chest drain insertion View source Failure to establish clinical necessity for chest drain insertion View source Lack of Acute or Basic Life Support training for the radiologist View source Reliance on emergency paramedic attendance to provide hospital care before transfer View source Insufficient nursing competence in resuscitation and chest drain management View source Lack of independent radiological indications for chest drain insertion View source Chest drain insertion decisions influenced by the day of the week View source Failure to radiologically confirm the position of a non-draining chest drain View source Failure to record observations before and after chest drain procedures View source Admission of acutely unwell patients without onsite HDU/ITU facilities View source Absence of operational protocols for hospital emergency situations View source Absence of HDU or ITU capability for hospital emergency situations View source See 20 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Critall · 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 Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Minimal respiratory consultant documentation
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission . There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Outdated chest drain management protocol lacking complication actions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose .
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
Wider context from the report “8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains .
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Excessive patient caseloads and unclear experience among senior resident medical staff
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72 . This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical examination
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete consent detailing chest drain complications
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications , radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to request repeat inflammatory markers
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor communication of the post-procedure care plan to ward staff
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use a WHO checklist for radiological interventions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist , no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Proactive chest drain insertion without objective clinical evidence
Wider context from the report “9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented management plan
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place , no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use real-time ultrasound guidance for chest drain insertion
Wider context from the report “5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’ . I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony).
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clinical necessity for chest drain insertion
Wider context from the report “3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity .
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of Acute or Basic Life Support training for the radiologist
Wider context from the report “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Reliance on emergency paramedic attendance to provide hospital care before transfer
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital .
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of independent radiological indications for chest drain insertion
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant , a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Chest drain insertion decisions influenced by the day of the week
Wider context from the report “4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week .
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to radiologically confirm the position of a non-draining chest drain
Wider context from the report “6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining . I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s death.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations before and after chest drain procedures
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Admission of acutely unwell patients without onsite HDU/ITU facilities
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration . The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of operational protocols for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” 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 Surrey County Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of HDU or ITU capability for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report
Concerns raised 19 Lack of daily creatine kinase monitoring during propofol infusions View source Lack of national understanding and acceptance of safe propofol amounts View source Lack of consultant ward rounds in weekend urology on-call arrangements View source Delays in urology review of emergency admissions View source Failure to act on or escalate elevated Early Warning Scores View source Undue reliance on outdated admission blood tests for clinical assessment View source Failure to create and adhere to guidelines or protocols for propofol use View source Lack of active management to expedite physician review and ITU admission View source Failure to recognise and treat sepsis in accordance with national guidelines View source Lack of continual assessment for complications of propofol-related infusion syndrome View source Lack of clarity about propofol infusion duration, volume and dose View source Inadequate assessment of renal stone size and hydronephrosis View source Lack of a protocol for propofol use in ITU View source Inadequate supervision of out-of-hours urology trainees View source Lack of medical supervision and control of propofol use in ITU View source Lack of knowledge or implementation of published on-call national guidelines View source Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation View source Lack of understanding of atypical adult presentation of propofol-related infusion syndrome View source Failure of critical care outreach to recognise and escalate concerns of sepsis View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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 Surrey County Hospital; 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
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations