Recurring concern

Unreliable sedation guidance and practice

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First reported 3 Mar 2016•Latest report 13 May 2024

Definition

What this concern includes

Includes failures in sedation guidance, training, decision-making, medication selection, dosing and monitoring across emergency, procedural and clinical care when these directly impair safe sedation.

Not included

Excludes general emergency-response, clinical or medication training deficiencies that are not specifically related to sedation.
Excludes medication administration, prescribing or monitoring failures where sedation is not the material safety concern.
Excludes treatment or monitoring failures after sedation has been safely selected and administered.
Excludes unrelated analgesia or restraint practices unless the assertion explicitly concerns sedation.

Reports: 6
Individual concerns: 11
Date range: 2016–2024
Stated actions: 12

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Association of Ambulance Chief Executives1

Barts Health NHS Trust1

British Cardiovascular Intervention Society1

British Society Of Interventional Radiology1

College of Policing1

Department of Health and Social Care1

Frimley Park Hospital1

NHS England1

Nottinghamshire Healthcare NHS Foundation Trust1

South Central Ambulance Service NHS Foundation Trust1

Thames Valley Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

13 May2024
East London
Concerns raised1
1. Failure to make and evidence a reasoned decision on rapid tranquilisation
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
  Stated by Barts Health NHS TrustStated planned
2. Action
  Arrange consultant attendance for specified emergency procedures in line with professional guidance.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
  Stated by Barts Health NHS TrustStated in progress
Respondent positions 1
1. Position
  The primarily local concerns are for Barts Health NHS Foundation Trust to address.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Elvon Paul Randolph Morton · 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

Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

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.
PFD Monitor interpretation
Failure to make and evidence a reasoned decision on rapid tranquilisation
Wider context from the report
“3. The decision to sedate Mr Morton was flawed. The lack of contemporary documentation impeded an effective coronary investigation and review of that clinical decision. In the absence of clear and reasoned evidence of decision making, weight must be attached to evidence heard that Elvon’s; size, sex and race triggered a heightened response by hospital staff to his agitation, leading to security officers being called. It was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made. ”
Source location
Elvon Paul Randolph Morton · Prevention of Future Deaths report
Page 3 · concerns
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
Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.

Verbatim wording from the response
“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation. The induction programme will be delivered and evidenced retained. A specific presentation relating to the Mental Capacity Act (MCA) its implementation in practice and the wider considerations will be delivered within the teaching programmes for all grades within A&E.”

Source location
Response from Barts Health
Page 2 · response
Published 14 May 2024
Open published response
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
Arrange consultant attendance for specified emergency procedures in line with professional guidance.

Verbatim wording from the response
“The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance). With the benefit of hindsight, consultant presence would have provided support for the trainees.”

Source location
Response from Barts Health
Page 2 · response
Published 14 May 2024
Open published response
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
Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.

Verbatim wording from the response
“For assurance and complete clarity, the new rapid tranquilisation guidance which in the process of being recently updated is applicable to the whole of Barts Health has a very clear wording at the top “This guidance is not to be used in the hypoxic, hypovolemic or septic patient or in one in which intubation as opposed to rapid tranquilisation is required”. This will ensure decision making is senior and clearly documented if and when the guidance cannot be followed in cases where there is sound clinical justification to do so.”

Source location
Response from Barts Health
Page 3 · response
Published 14 May 2024
Open published response
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 primarily local concerns are for Barts Health NHS Foundation Trust to address.

Verbatim wording from the response
“In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.”

Source location
Response from DHSC
Page 1 · response
Published 14 May 2024
Open published response
15 Dec2022
Berkshire
Concerns raised1
1. Incorrect training about chemical sedation by first responding ambulance staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Remove references to chemical sedation from training.
  Stated by College of PolicingStated planned
2. Action
  Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
3. Action
  Update ABD and restraint training materials to clarify containment, ambulance response expectations, medical emergency status, and prohibited chemical-sedation references.
  Stated by Thames Valley PoliceStated completed
AI-generated summary

Neal Terence Saunders · 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

Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.

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.
PFD Monitor interpretation
Incorrect training about chemical sedation by first responding ambulance staff
Wider context from the report
“Brief summary of matters of concern Police training There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided. The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect. The key concerns around training can be summarised as follows:- 1. How long is “prolonged” restraint? 2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified). 3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making. 4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant. 5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively. 6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded? Training generally I raise 2 points here: 1. Checking of guidance which is infrequently used 2. Joint training with ambulance services Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017. I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website. I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance. In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers. Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this. In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive. I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly. It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely. Ambulance issues One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance. I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management. There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology. ”
Source location
Neal Terence Saunders · Prevention of Future Deaths report
Page 3 · concerns
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
Remove references to chemical sedation from training.

Verbatim wording from the response
“4. References to ‘chemical sedation’ will be removed from training.”

Source location
Response from College of Policing
Page 2 · response
Published 19 December 2022
Open published response
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
Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.

Verbatim wording from the response
“To confirm, your Regulation 28 report was predominantly aimed at the national bodies responsible for providing training and guidance to police and ambulance service emergency personnel. Within that report, you asked the South Central Ambulance Service to consider working jointly with Thames Valley Police (TVP) to review our policies and training as suggested by our Medical Director during the evidence he provided to you.”

Source location
Response from South Central Ambulance Service
Page 1 · response
Published 19 December 2022
Open published response
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
Update ABD and restraint training materials to clarify containment, ambulance response expectations, medical emergency status, and prohibited chemical-sedation references.

Verbatim wording from the response
“material on this issue has been updated to ensure that Officers understand this point.”

Source location
Response from Thames Valley Police
Page 3 · response
Published 19 December 2022
Open published response
19 Jan2022
Nottinghamshire
Concerns raised2
1. Failure to ensure the correct type and dose of sedation medication
2. Poor documentation of sedation medication
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The administered dosages were within British National Formulary guidelines and were assessed as unlikely to harm physical health.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustDisputes the concern
AI-generated summary

Michelle Whitehead · 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

Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

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.
PFD Monitor interpretation
Failure to ensure the correct type and dose of sedation medication
Wider context from the report
“1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”
Source location
Michelle Whitehead · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor documentation of sedation medication
Wider context from the report
“1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”
Source location
Michelle Whitehead · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 dosages were within British National Formulary guidelines and were assessed as unlikely to harm physical health.

Verbatim wording from the response
“A medication error did occur during Mrs. Whitehead’s care. This involved the incorrect dose of administered Oral Diazepam being communicated to the Ward Manager and Duty Doctor. With this incorrect information they agreed to administer Rapid Tranquillisation in the form of an Intramuscular injection of Lorazepam.”

Source location
2022-0016-Response-from-Nottinghamshire-Healthcare_Published
Page 1 · response
Published 24 January 2022
Open published response
24 Jul2017
Milton Keynes
Concerns raised2
1. Insufficient dissemination of sedation-use guidelines to clinicians undertaking sedation
2. Lack of locally developed sedation training for clinical staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Patricia Lilian Parker · 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

Patricia Lilian Parker suffered a cardiac arrest after sedation for an endoscopy on 5 January 2017 and died on 8 January 2017 despite resuscitation. The report identified a failure to follow the Trust’s intravenous sedation policy and BNF recommendations on titrating sedation, and raised concerns about clinicians’ awareness and training regarding sedation, particularly for older people.

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.
PFD Monitor interpretation
Insufficient dissemination of sedation-use guidelines to clinicians undertaking sedation
Wider context from the report
“(1)That the numerous guidelines relating to the use of sedation should be more widely brought to the attention of all clinicians undertaking sedation. ”
Source location
Patricia Lilian Parker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of locally developed sedation training for clinical staff
Wider context from the report
“(2) That NHS England should highlight the problems arising from the use of sedation particularly in the elderly and encourage all Hospitals to develop training locally for their clinical staff. ”
Source location
Patricia Lilian Parker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Oct2016
Surrey
Concerns raised3
1. Incoherent and inconsistent sedation practice for catheter laboratory procedures
2. Inappropriate use of sedation for cardiac electrophysiological procedures
3. Lack of a sedation policy for cardiac electrophysiological procedures
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Maintain a cardiology guideline for intravenous conscious sedation covering dose titration, monitoring, observation frequency and training.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Review and revise the Trustwide guideline for intravenous conscious sedation across clinical settings to standardise processes.
  Stated by Frimley Health NHS Foundation TrustStated in progress
3. Action
  Share sedation-related learning through the Cardiology team’s morbidity and mortality processes and reinforce expectations in the Cardiac Catheter Laboratory.
  Stated by Frimley Health NHS Foundation TrustStated completed
1. Action
  Progress internal ratification of the revised Trustwide intravenous conscious sedation guideline.
  Stated by Frimley Health NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  A cardiology intravenous conscious sedation guideline existed at the time and addressed many concerns raised at the inquest.
  Stated by Frimley Health NHS Foundation TrustDisputes the concern
AI-generated summary

Peter John Keep · 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

Peter John Keep, an 82-year-old man, was admitted after a fall and underwent pacemaker insertion for Mobitz type 2 heart block. During the difficult procedure he received several sedative and analgesic doses, lost his airway, and suffered cardiac tamponade from perforation of the right ventricle; he later had a cardiac arrest and died in intensive care. The principal concerns included inappropriate and inconsistent sedation, inadequate sedation policies and training, and a lack of action plans for procedure intolerance, airway loss, or difficulty placing the pacemaker wire.

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.
PFD Monitor interpretation
Incoherent and inconsistent sedation practice for catheter laboratory procedures
Wider context from the report
“3. An incoherent approach to sedation for procedures in the catheter Lab. with different clinicians using different drugs inconsistently e.g. use of an anxiolytic for discomfort. ”
Source location
Peter John Keep · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inappropriate use of sedation for cardiac electrophysiological procedures
Wider context from the report
“1. Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures. ”
Source location
Peter John Keep · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a sedation policy for cardiac electrophysiological procedures
Wider context from the report
“1. Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures. ”
Source location
Peter John Keep · Prevention of Future Deaths report
Page 2 · concerns
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
Maintain a cardiology guideline for intravenous conscious sedation covering dose titration, monitoring, observation frequency and training.

Verbatim wording from the response
“Contrary to the evidence heard at the Inquest, the Cardiology Department does have a guideline for intravenous conscious sedation which was in place at the time of Mr Keep’s procedure and which addresses many of the concerns raised through the Inquest including titration of drug doses, monitoring expected to be used, frequency of observations and training (copy enclosed).”

Source location
2016-0362-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 February 2017
Open published response
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
Review and revise the Trustwide guideline for intravenous conscious sedation across clinical settings to standardise processes.

Verbatim wording from the response
“The Trust has also used your letter and Regulation 28 as an opportunity to relaunch the Trust Safe Sedation Committee which will be chaired by ████████ Deputy Medical Director and Chief of Service for Anaesthetics. The Committee are currently reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults addressing intravenous sedation in all clinical settings standardising the processes followed. The policy is in draft and going through the Trust’s internal ratification processes together with the draft terms of reference for the Sedation Group (drafts of both attached).”

Source location
2016-0362-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 February 2017
Open published response
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
Share sedation-related learning through the Cardiology team’s morbidity and mortality processes and reinforce expectations in the Cardiac Catheter Laboratory.

Verbatim wording from the response
“The Cardiology team have discussed Mr Keep’s case through their internal Morbidity & Mortality processes to share the learning from this case and to ensure there is awareness of the expectations in terms of conscious sedation within the Cardiac Catheter Laboratory.”

Source location
2016-0362-Response-by-Frimley-Health-NHS-Trust
Page 2 · response
Published 26 February 2017
Open published response
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
Progress internal ratification of the revised Trustwide intravenous conscious sedation guideline.

Verbatim wording from the response
“The Trust has also used your letter and Regulation 28 as an opportunity to relaunch the Trust Safe Sedation Committee which will be chaired by ████████ Deputy Medical Director and Chief of Service for Anaesthetics. The Committee are currently reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults addressing intravenous sedation in all clinical settings standardising the processes followed. The policy is in draft and going through the Trust’s internal ratification processes together with the draft terms of reference for the Sedation Group (drafts of both attached).”

Source location
2016-0362-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 February 2017
Open published response
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
A cardiology intravenous conscious sedation guideline existed at the time and addressed many concerns raised at the inquest.

Verbatim wording from the response
“Contrary to the evidence heard at the Inquest, the Cardiology Department does have a guideline for intravenous conscious sedation which was in place at the time of Mr Keep’s procedure and which addresses many of the concerns raised through the Inquest including titration of drug doses, monitoring expected to be used, frequency of observations and training (copy enclosed).”

Source location
2016-0362-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 February 2017
Open published response
3 Mar2016
Birmingham and Solihull
Concerns raised2
1. Failure to introduce safeguards against air entry into the vascular system during procedures with conscious sedation
2. Lack of widespread awareness of air-entry risk during procedures with conscious sedation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Circulated the report to BCIS members through its official newsletter.
  Stated by British Cardiovascular Intervention SocietyStated completed
2. Action
  Passed report details to the British Heart Rhythm Society for onward circulation to electrophysiology colleagues.
  Stated by British Cardiovascular Intervention SocietyStated completed
AI-generated summary

Ronald Reginald BENTLEY · 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

Ronald Reginald BENTLEY died at Queen Elizabeth Hospital Birmingham on 20 September 2015 following an air embolism during an elective percutaneous closure procedure performed under conscious sedation, which resulted in hypoxic brain injury. The principal concern was that the risk of air entering the vascular system when the patient breathed deeply while the sheath was open had not been recognised, meaning patients at other cardiac centres could remain at risk unless the risk and appropriate safeguards were widely known.

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.
PFD Monitor interpretation
Failure to introduce safeguards against air entry into the vascular system during procedures with conscious sedation
Wider context from the report
“During the inquest the Consultant Cardiologist, ████████ gave evidence that before the procedure it had not occurred to him that in performing the procedure with conscious sedation there is a risk that the patient breathes deeply at the 4 or so points when the sheath is open air could enter the vascular system. He stated that there was no warning of this risk that he was aware of at the time and he has since made enquiries of the manufacturers of the TorqVue sheath system used, St. Jude, and they have stated that they had not identified this as a risk of conscious sedation. ████████ has since canvassed colleagues both nationally and internationally and this risk of the procedure when proceeding with conscious sedation had not been identified by anyone he had spoken to. ████████ stated that as a result of Mr. Bentley’s death the University Hospital of Birmingham NHS Trust has taken the following steps to reduce the risk of these events arising again: (a) all such procedures to be undertaken with a general anaesthetic unless an absolute need for conscious sedation; (b) ensuring LA pressure is above 10mmHg before introducing the sheath; (c) all exchanges on to the sheath to be done in a water bath so if suction does occur it is sterile solution sucked not air; (d) the amount of time the TorqVue sheath is within the left atrium has been reduced by changing to a smaller sheath as soon as possible in conjunction with introducing the occlusion device as soon as the left atrium is entered. However, the Coroner’s concern is that unless this risk is widely known, and safeguards introduced as a consequence, there continues to be a risk that patients at other Cardiac Centres could suffer the same complication. ”
Source location
Ronald Reginald BENTLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of widespread awareness of air-entry risk during procedures with conscious sedation
Wider context from the report
“During the inquest the Consultant Cardiologist, ████████ gave evidence that before the procedure it had not occurred to him that in performing the procedure with conscious sedation there is a risk that the patient breathes deeply at the 4 or so points when the sheath is open air could enter the vascular system. He stated that there was no warning of this risk that he was aware of at the time and he has since made enquiries of the manufacturers of the TorqVue sheath system used, St. Jude, and they have stated that they had not identified this as a risk of conscious sedation. ████████ has since canvassed colleagues both nationally and internationally and this risk of the procedure when proceeding with conscious sedation had not been identified by anyone he had spoken to. ████████ stated that as a result of Mr. Bentley’s death the University Hospital of Birmingham NHS Trust has taken the following steps to reduce the risk of these events arising again: (a) all such procedures to be undertaken with a general anaesthetic unless an absolute need for conscious sedation; (b) ensuring LA pressure is above 10mmHg before introducing the sheath; (c) all exchanges on to the sheath to be done in a water bath so if suction does occur it is sterile solution sucked not air; (d) the amount of time the TorqVue sheath is within the left atrium has been reduced by changing to a smaller sheath as soon as possible in conjunction with introducing the occlusion device as soon as the left atrium is entered. However, the Coroner’s concern is that unless this risk is widely known, and safeguards introduced as a consequence, there continues to be a risk that patients at other Cardiac Centres could suffer the same complication. ”
Source location
Ronald Reginald BENTLEY · Prevention of Future Deaths report
Page 1 · concerns
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
Circulated the report to BCIS members through its official newsletter.

Verbatim wording from the response
“Further to you circulating the report to the British Cardiovascular Intervention Society (BCIS) and the British Society of Interventional Radiology (BSIR), I am writing to inform you that BCIS arranged for circulation to its members via its official newsletter on 26 April 2016 and have also passed on details to the British Heart Rhythm Society (BHRS) so they can arrange for circulation to electrophysiology colleagues.”

Source location
2016-0086-Response-by-BCIS
Page 1 · response
Published 3 March 2016
Open published response
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
Passed report details to the British Heart Rhythm Society for onward circulation to electrophysiology colleagues.

Verbatim wording from the response
“Further to you circulating the report to the British Cardiovascular Intervention Society (BCIS) and the British Society of Interventional Radiology (BSIR), I am writing to inform you that BCIS arranged for circulation to its members via its official newsletter on 26 April 2016 and have also passed on details to the British Heart Rhythm Society (BHRS) so they can arrange for circulation to electrophysiology colleagues.”

Source location
2016-0086-Response-by-BCIS
Page 1 · response
Published 3 March 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to make and evidence a reasoned decision on rapid tranquilisation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Incorrect training about chemical sedation by first responding ambulance staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Failure to ensure the correct type and dose of sedation medication

Poor documentation of sedation medication

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Insufficient dissemination of sedation-use guidelines to clinicians undertaking sedation

Lack of locally developed sedation training for clinical staff

Concerns raised3

Incoherent and inconsistent sedation practice for catheter laboratory procedures

Inappropriate use of sedation for cardiac electrophysiological procedures

Lack of a sedation policy for cardiac electrophysiological procedures

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to introduce safeguards against air entry into the vascular system during procedures with conscious sedation

Lack of widespread awareness of air-entry risk during procedures with conscious sedation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 3

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 4

Respondent positions 1

Actions described in response 2