Maria De Oliveria Alva LOPES · Prevention of Future Deaths report

On 5th December 2013 I commenced an investigation into the death of Maria De Oliveria Alva LOPES, 31 years of. The investigation concluded at the end of the inquest on 26th June 2014. The medical cause of death given was:

1a. Multiorgan failure
1b. Rhabdomyolysis
1c. Propofol related infusion syndrome
1d. Complications of urosepsis

2.

My narrative conclusion was:

Mrs Lopes has died from a rare reaction to propofol that has been used to support ventilation in order to aid her recovery from the consequences of septic shock, that has been caused by a delay in the recognition of urosepsis and a failure to receive timely medical treatment

Mrs Lopes presented to A&E on the 1st September 2012 with a short history of sudden onset of pain suggestive of renal colic. She had an IVU and was found to have a stone in her left ureter with associated hydronephrosis. She was admitted and seen the following day for the first time on the routine ward round undertaken by the on call urology registrar. Signs of Systemic Inflammatory Response syndrome (SIRS) were present at the time of the ward round but were not recognised as such and the management plan put in place was therefore inadequate. Mrs Lopes developed increasing signs of sepsis and despite documentation in the form of arterial blood gases and blood results demonstrating sepsis (raised CRP and lactate with hypoxaemia) and review by the critical care outreach and continuously raised Early Warning Scores its severity was not recognised or appropriately escalated and opportunities were lost to treat the sepsis in a timely fashion. Referral and transfer to the Intensive care unit was not properly expedited and resulted in a further delay in treatment. Mrs Lopes required intubation and ventilation and inotropic support for septic shock and multiorgan failure. Her sepsis was resolving after treatment with antibiotics and a nephrostomy but recovery was slow requiring prolonged ventilation using propofol for sedation. Mrs Lopes began to deteriorate on 7th September, 6 days after admission to ICU, with increasing oxygen requirements on which was thought to be septic in origin. Despite intensive investigation no source of sepsis was found. She continued to deteriorate throughout 8th September developing myoglobulinuria, a rising creatine kinase and hyperkalaemia from rhabdomyolysis. Supportive management of the hyperkalaemia was not successful and she became too haemodynamically unstable for haemofiltration and despite other supportive measures, she died on 9th September 2012.

I heard expert evidence from two experts who both agreed the ultimate cause of death was propofol related infusion syndrome causing rhabdomyolysis and associated sequelae and this was a consequence of a slow recovery and weaning from ventilation as a result of the severe sepsis. The amount of propofol given was likely to be in excess of the recommended dose (both in length of time used and amount given) with control primarily undertaken by the nursing team.

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
2. A general lack of knowledge or implementation of published ‘on call’ national guidelines
3. The overall supervision of out of hours urology trainees within the current system
4. The review of emergency admissions by urology (not on day of admission, once daily)
5. The recognition and treatment of sepsis as per national guidelines
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
7. The lack of active management to expedite physician’s review and to facilitate admission to ITU
8. Failure to recognise and therefore escalate concerns of sepsis by critical care outreach team
9. Failure to act on or escalate elevated Early Warning Scores as per hospital protocol
10. Lack of clarity to the length, volume and dose of propofol infusion to be given in ITU
11. Lack of medical supervision and control of the use of propofol in ITU (no protocol in place)
12. Consideration for the use of daily Creatine Kinase levels when propofol infusions are given
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
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
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)