PFD report

Joyce Beatrice TOZER · Prevention of Future Deaths report

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Issued 15 Dec 2015•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Administration of hypertonic Omnipaque through central lines
    Part of recurring concern: Unsafe administration of intravascular contrast media
  2. Frequent administration of Omnipaque doses exceeding manufacturer guidelines
    Part of recurring concern: Unsafe administration of intravascular contrast mediaPart of recurring concern: Unsafe medication administration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.

    Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Administration of hypertonic Omnipaque through central lines

Wider context from the report

“(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access. At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used. I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered, sometimes through central lines, and this practice could be exposing interventional radiology patients to risks from toxicity. ”

Is this part of a recurring concern?

Yes — Unsafe administration of intravascular contrast media.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Frequent administration of Omnipaque doses exceeding manufacturer guidelines

Wider context from the report

“(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access. At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used. I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered, sometimes through central lines, and this practice could be exposing interventional radiology patients to risks from toxicity. ”

Is this part of a recurring concern?

Yes — Unsafe administration of intravascular contrast media; Unsafe medication administration.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.

Verbatim wording from the response

“A round table meeting was held on 24th December to discuss whether an overdose was a causative factor in the death of the deceased. The roundtable review noted that the deceased had become unwell following administration of 100ml Visipaque (Omnipaque was incorrectly documented in the medical notes, the correct contrast agent is recorded on the Trust’s imaging system. 100mls is considered to be a standard dose; Visipaque is iso-osmolar and therefore theoretically less toxic than Omnipaque).”

Source location

Joyce-Tozer-Response
Page 1 · response
Published 15 December 2015

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.

Verbatim wording from the response

“1. The radiographer administering the contrast acted entirely appropriately and within the limitations of the expanded practice IV protocol;”

Source location

Joyce-Tozer-Response
Page 1 · response
Published 15 December 2015

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

Data last updated 7 September 2026