Royal Surrey County Hospital

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First report 11 Jul 2014•Latest report 16 May 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Royal Surrey County Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 May2016
Surrey
Concerns raised23
1. Minimal respiratory consultant documentation
2. Outdated chest drain management protocol lacking complication actions
3. Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
1. Excessive patient caseloads and unclear experience among senior resident medical staff
2. Failure to document clinical examination
3. Failure to complete consent detailing chest drain complications
4. Failure to request repeat inflammatory markers
5. Poor communication of the post-procedure care plan to ward staff
6. Failure to use a WHO checklist for radiological interventions
7. Proactive chest drain insertion without objective clinical evidence
8. Absence of a documented management plan
9. Failure to use real-time ultrasound guidance for chest drain insertion
10. Failure to establish clinical necessity for chest drain insertion
11. Lack of Acute or Basic Life Support training for the radiologist
12. Reliance on emergency paramedic attendance to provide hospital care before transfer
13. Insufficient nursing competence in resuscitation and chest drain management
14. Lack of independent radiological indications for chest drain insertion
15. Chest drain insertion decisions influenced by the day of the week
16. Failure to radiologically confirm the position of a non-draining chest drain
17. Failure to record observations before and after chest drain procedures
18. Admission of acutely unwell patients without onsite HDU/ITU facilities
19. Absence of operational protocols for hospital emergency situations
20. Absence of HDU or ITU capability for hospital emergency situations
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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
11 Jul2014
Surrey
Concerns raised19
1. Lack of daily creatine kinase monitoring during propofol infusions
2. Lack of national understanding and acceptance of safe propofol amounts
3. Lack of consultant ward rounds in weekend urology on-call arrangements
1. Delays in urology review of emergency admissions
2. Failure to act on or escalate elevated Early Warning Scores
3. Undue reliance on outdated admission blood tests for clinical assessment
4. Failure to create and adhere to guidelines or protocols for propofol use
5. Lack of active management to expedite physician review and ITU admission
6. Failure to recognise and treat sepsis in accordance with national guidelines
7. Lack of continual assessment for complications of propofol-related infusion syndrome
8. Lack of clarity about propofol infusion duration, volume and dose
9. Inadequate assessment of renal stone size and hydronephrosis
10. Lack of a protocol for propofol use in ITU
11. Inadequate supervision of out-of-hours urology trainees
12. Lack of medical supervision and control of propofol use in ITU
13. Lack of knowledge or implementation of published on-call national guidelines
14. Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation
15. Lack of understanding of atypical adult presentation of propofol-related infusion syndrome
16. Failure of critical care outreach to recognise and escalate concerns of sepsis
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

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

Reports, concerns and published responses

Reports over time

Concerns raised23

Minimal respiratory consultant documentation

Outdated chest drain management protocol lacking complication actions

Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence

Excessive patient caseloads and unclear experience among senior resident medical staff

Failure to document clinical examination

Failure to complete consent detailing chest drain complications

Failure to request repeat inflammatory markers

Poor communication of the post-procedure care plan to ward staff

Failure to use a WHO checklist for radiological interventions

Proactive chest drain insertion without objective clinical evidence

Absence of a documented management plan

Failure to use real-time ultrasound guidance for chest drain insertion

Failure to establish clinical necessity for chest drain insertion

Lack of Acute or Basic Life Support training for the radiologist

Reliance on emergency paramedic attendance to provide hospital care before transfer

Insufficient nursing competence in resuscitation and chest drain management

Lack of independent radiological indications for chest drain insertion

Chest drain insertion decisions influenced by the day of the week

Failure to radiologically confirm the position of a non-draining chest drain

Failure to record observations before and after chest drain procedures

Admission of acutely unwell patients without onsite HDU/ITU facilities

Absence of operational protocols for hospital emergency situations

Absence of HDU or ITU capability for hospital emergency situations

Concerns raised19

Lack of daily creatine kinase monitoring during propofol infusions

Lack of national understanding and acceptance of safe propofol amounts

Lack of consultant ward rounds in weekend urology on-call arrangements

Delays in urology review of emergency admissions

Failure to act on or escalate elevated Early Warning Scores

Undue reliance on outdated admission blood tests for clinical assessment

Failure to create and adhere to guidelines or protocols for propofol use

Lack of active management to expedite physician review and ITU admission

Failure to recognise and treat sepsis in accordance with national guidelines

Lack of continual assessment for complications of propofol-related infusion syndrome

Lack of clarity about propofol infusion duration, volume and dose

Inadequate assessment of renal stone size and hydronephrosis

Lack of a protocol for propofol use in ITU

Inadequate supervision of out-of-hours urology trainees

Lack of medical supervision and control of propofol use in ITU

Lack of knowledge or implementation of published on-call national guidelines

Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation

Lack of understanding of atypical adult presentation of propofol-related infusion syndrome

Failure of critical care outreach to recognise and escalate concerns of sepsis