Concerns raised 3 Lack of national guidelines for central venous catheter removal View source Electronic clinical notes permitting alteration of author times View source Failure to provide constant visual observation after central venous catheter removal View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
John Waite · 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
John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.
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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for central venous catheter removal
Wider context from the report “iv. There are no national guidelines in relation to the removal of central venous catheters, particularly temporary central venous catheters for haemodialysis. The evidence at the Inquest confirmed that the Secretary of State, the Renal Association, the British Renal Society and the Intensive Care Society would be appropriate organisations to consider the issue of a national policy, protocol and guidance relating to the removal of central venous catheters.
” 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Electronic clinical notes permitting alteration of author times
Wider context from the report “4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note . The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored .
” 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant visual observation after central venous catheter removal
Wider context from the report “ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter.
iii. Following the death of the Deceased the Salford Royal NHS Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications.
A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter.
The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death.
The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time.
” Open source report
Concerns raised 1 Failure of tracheostomy tube lengths to match increasing patient size View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dilys Jenkins · 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
Dilys Jenkins, who had undergone cardiac surgery and subsequently required a tracheostomy, died after the tracheostomy became dislodged, leading to respiratory and cardiac arrest. The Coroner was concerned that the tube’s length may have contributed to the dislodgement and that tracheostomy design and sizing had not kept pace with increasing population size.
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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Failure of tracheostomy tube lengths to match increasing patient size
Wider context from the report “Both ████████ and ████████ were of the view that the tracheostomy manufacturers had not kept pace with the developments in the population towards larger size . The tracheostomy was a size 8 Portex tracheostomy tube which I heard had a length of 75.9 mm ████████ gave evidence that nowadays this length can be inappropriate and that a length of 85.9 mm may be more desirable. They both referred to learned papers which enclose with this Regulation 28 Notice. I have had regard to Chapter 15 in particular of the paper “Major complications of airway management in the UK” (March 2011) and to the article in Anaesthesia 2008, 63, pages 302 – 306 “An investigation into the length of standard tracheostomy tubes in critical care patients”. This recommendation that the length of the tube be increased by 1 cm and the tube redesign to an angle of 110 – 120 degrees to allow optimal tracheal placement. I concluded that the tube will not lie comfortably if its stoma or intra-tracheal length is too short or too long. While the cause of the dislodgment in the case of Dilys Jenkins is unknown the Coroner is concerned that incorrect length may have been a factor .
The Coroner is concerned that the tracheostomy industry should be encouraged to change the length of the tracheostomy tube to match the increasing size of the population , and believes the Intensive Care Society is in the best position to influence industry in this regard.
” Open source report
11 Jul 2014 Maria De Oliveria Alva LOPES · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 19 Lack of daily creatine kinase monitoring during propofol infusions View source Lack of national understanding and acceptance of safe propofol amounts View source Lack of consultant ward rounds in weekend urology on-call arrangements View source Delays in urology review of emergency admissions View source Failure to act on or escalate elevated Early Warning Scores View source Undue reliance on outdated admission blood tests for clinical assessment View source Failure to create and adhere to guidelines or protocols for propofol use View source Lack of active management to expedite physician review and ITU admission View source Failure to recognise and treat sepsis in accordance with national guidelines View source Lack of continual assessment for complications of propofol-related infusion syndrome View source Lack of clarity about propofol infusion duration, volume and dose View source Inadequate assessment of renal stone size and hydronephrosis View source Lack of a protocol for propofol use in ITU View source Inadequate supervision of out-of-hours urology trainees View source Lack of medical supervision and control of propofol use in ITU View source Lack of knowledge or implementation of published on-call national guidelines View source Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation View source Lack of understanding of atypical adult presentation of propofol-related infusion syndrome View source Failure of critical care outreach to recognise and escalate concerns of sepsis View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maria De Oliveria Alva LOPES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Failure of critical care outreach to recognise and escalate concerns of sepsis
Wider context from the report “8. Failure to recognise and therefore escalate concerns of sepsis by critical care outreach team
” Open source report
29 Apr 2014 Joanne Elizabeth Oliver · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 2 Lack of an appropriate written risk-assessment framework for transferring critically ill patients View source Lack of detailed guidance for decisions about transferring critically ill patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joanne Elizabeth Oliver · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joanne Elizabeth Oliver, aged 31, was transferred by air ambulance after treatment for H1N1 influenza and ECMO, but her condition deteriorated after arrival at Manchester Royal Infirmary. She developed severe metabolic acidosis with high carbon dioxide and potassium levels, suffered cardiac arrest, and died. The report identified an unacceptable delay in obtaining blood gas analysis and monitoring, and raised concerns about the lack of detailed guidance and risk assessment for transferring critically ill patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate written risk-assessment framework for transferring critically ill patients
Wider context from the report “(1) Evidence was given that there is no detailed guidance from the Department of Health or the Intensive Care Society to assist in the decision to transfer a critically ill patient. Some guidance is given in a document “Guidelines for the transport of the critically ill adult (2011)” but that is focused on the actual transfer of the patient and not the decision whether to transfer or not, or when this should take place.
(2) It would be of assistance to doctors making the decision to transfer, and would help them to justify the transfer if it was later questioned, if Guidelines could be given to assist in the preparation of a written risk assessment . The evidence was that the “MEWS Score system”, now the “NEW Score system” was never designed with critically ill patients in mind .
(3) Any risk assessment would need to consider:
(a) The multitude of background clinical factors that indicate whether the patient was fit to travel
(b) The practical tests that should be undertaken to confirm fitness for transfer eg trial of transport ventilator, assessment of biochemical stability when renal replacement therapy is withheld
(c) The seniority of the doctors who make that decision, and the numbers of doctors to be involved
(d) Whether it is in the best interest of the patient to make the transfer
(e) The pressures for beds where there is, as in this case, an epidemic forcing doctors to make difficult decisions on the priority of patients.
(f) The danger that a patient is moved out to allow another one in when the first patient is not fully in a state to be moved.
(g) The risk that the doctor responsible for supervising and travelling with the patient may be pressured into agreeing to the transfer
(h) The distance and time of the journey
(i) The risks of deterioration during that journey time
(j) Whether there are risks that the journey time will be extended
(k) Whether it is by road or air, and any factors that arise from the mode of transport
(l) The equipment and medication available during the transfer
(m) The medical staff to accompany the patient and their skills in transferring patients
(n) The actions to be taken by the transferring or receiving doctors on receipt of the patient to confirm their stability after transfer, and the timeframe within which this should be undertaken
(o) The information that should be given to patients or their next of kin prior to transfer such that they too are aware of the rationale for transfer and the intrinsic risks
(p) The standards of documentation for the decision-making in these circumstances and in the above domains
(q) Audit of outcomes of patient transfers (acknowledging that outcomes will not necessarily be collated for those patients deemed unsuitable for transfer for whatever reason)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed guidance for decisions about transferring critically ill patients
Wider context from the report “(1) Evidence was given that there is no detailed guidance from the Department of Health or the Intensive Care Society to assist in the decision to transfer a critically ill patient . Some guidance is given in a document “Guidelines for the transport of the critically ill adult (2011)” but that is focused on the actual transfer of the patient and not the decision whether to transfer or not, or when this should take place .
(2) It would be of assistance to doctors making the decision to transfer, and would help them to justify the transfer if it was later questioned, if Guidelines could be given to assist in the preparation of a written risk assessment. The evidence was that the “MEWS Score system”, now the “NEW Score system” was never designed with critically ill patients in mind.
(3) Any risk assessment would need to consider:
(a) The multitude of background clinical factors that indicate whether the patient was fit to travel
(b) The practical tests that should be undertaken to confirm fitness for transfer eg trial of transport ventilator, assessment of biochemical stability when renal replacement therapy is withheld
(c) The seniority of the doctors who make that decision, and the numbers of doctors to be involved
(d) Whether it is in the best interest of the patient to make the transfer
(e) The pressures for beds where there is, as in this case, an epidemic forcing doctors to make difficult decisions on the priority of patients.
(f) The danger that a patient is moved out to allow another one in when the first patient is not fully in a state to be moved.
(g) The risk that the doctor responsible for supervising and travelling with the patient may be pressured into agreeing to the transfer
(h) The distance and time of the journey
(i) The risks of deterioration during that journey time
(j) Whether there are risks that the journey time will be extended
(k) Whether it is by road or air, and any factors that arise from the mode of transport
(l) The equipment and medication available during the transfer
(m) The medical staff to accompany the patient and their skills in transferring patients
(n) The actions to be taken by the transferring or receiving doctors on receipt of the patient to confirm their stability after transfer, and the timeframe within which this should be undertaken
(o) The information that should be given to patients or their next of kin prior to transfer such that they too are aware of the rationale for transfer and the intrinsic risks
(p) The standards of documentation for the decision-making in these circumstances and in the above domains
(q) Audit of outcomes of patient transfers (acknowledging that outcomes will not necessarily be collated for those patients deemed unsuitable for transfer for whatever reason)
” Open source report
Concerns raised 4 Failure to provide continuing patient education about Infliximab treatment risks View source Delays in initiating treatment when tuberculous meningitis is suspected View source Lack of protocols for pre-Infliximab tuberculosis screening View source Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment View source See 1 more concern
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
Craig Adam White · 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
Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.
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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuing patient education about Infliximab treatment risks
Wider context from the report “3 The need for continuing patient education about the risks of Infliximab treatment
” 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating treatment when tuberculous meningitis is suspected
Wider context from the report “4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected
” 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for pre-Infliximab tuberculosis screening
Wider context from the report “1 Protocols for pre-Infliximab treatment screening for tuberculosis
” 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 The Intensive Care Society; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Wider context from the report “2 Awareness of Health Care Professionals, in particular prescribers of the increased risk of TB inherent Infliximab treatment
” 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