Recurring concern

Inadequate controls for air embolism during invasive procedures

First to latest report 3 Mar 2016 — 1 Aug 2024

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
7

What this concern includes

Includes controls specifically dedicated to preventing, detecting, recognising or responding to air embolism during invasive procedures, including patient risk information, procedural safeguards, post-procedure investigation, monitoring, staff knowledge and training, and urgent treatment or escalation arrangements.

What is not included
  • Excludes generic informed-consent, clinical-training or post-operative-monitoring deficiencies where air embolism is not the material hazard.
  • Excludes embolic events unrelated to air entering the vascular system during an invasive procedure.
  • Excludes failures in treatment after air embolism has been reliably recognised and appropriate escalation has begun.
  • Excludes generic air, anaesthetic or vascular-access concerns without a direct air-embolism connection.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    Derryck Lynn CROCKER · 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

    Derryck Crocker underwent a CT-guided lung biopsy on 3 May 2023 and subsequently developed a cerebral air embolism, deteriorated, and died on 10 May 2023. The principal concerns were limited recognition of air embolism following invasive procedures, insufficient training and awareness across medical specialties, and delays in recognition and treatment that may increase the likelihood of death.

    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

    Lack of knowledge and training on recognising air embolism following invasive procedures

    Wider context from the report

    “1. I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure. I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors. While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly. ”

    Source location

    Derryck Lynn CROCKER · 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

    Re-issue a previously published air-embolism case report to raise awareness among members.

    Verbatim wording from the response

    “We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 8 August 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

    Consider providing specific air-embolism recognition and management guidance through the RCEM eLearning platform.

    Verbatim wording from the response

    “We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 8 August 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

    Add air embolism risks and management to appropriate educational events across relevant specialist sections during the coming year.

    Verbatim wording from the response

    “• The Presidents of all the relevant specialist Sections at the RSM have been asked to add in the risks of air embolism and its management to any appropriate educational events for the coming year.”

    Source location

    Response from Royal Society of Medicine
    Page 1 · response
    Published 8 August 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

    Use the Patient Safety Summit to teach medical students and junior doctors about air embolism risks and post-procedure signs and symptoms through an anaesthetics specialist.

    Verbatim wording from the response

    “• The Patient Safety section, which is running its 14th annual event for those at medical school and junior doctors, will use its Patient Safety Summit on 14 November 2024 to elevate the profile of the risks of air embolism and the signs and symptoms that might be seen following any invasive procedure. This will be covered by a specialist in anaesthetics.”

    Source location

    Response from Royal Society of Medicine
    Page 1 · response
    Published 8 August 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

    Air embolism is already covered in the core surgical curriculum, including central-line complications, and is commonly examined.

    Verbatim wording from the response

    “Assessment and management of thromboembolism is part of the scope of the MRCS/CST curriculum and the part of the syllabus which involves placement/management of central line will have in general included considerations for complications such as air embolism. An understanding of the risks of anaesthesia and medical gases is generic to surgical training.”

    Source location

    Response from Royal College of Surgeons of England
    Page 2 · response
    Published 8 August 2024

    Open published response

  2. Inner North London

    AI-generated summary

    Gary Day · 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

    Gary Day underwent an endoresection operation for choroidal melanoma at Moorfields Eye Hospital on 15 December 2020 and died the following day after becoming severely unwell from an air embolus. The concerns identified were that the risk of death from air embolism was not explained, no post-operative check for air embolus was carried out, and he was discharged without an overnight stay or access to his earlier medical notes when transferred to another hospital.

    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 inform patients undergoing endoresection of choroidal melanoma of the risk of air embolism and death

    Wider context from the report

    “I am concerned that: (a) Any patient who elects to have an endoresection operation of an choroidal melanoma faces a risk (however small) of air embolism and therefore death. This must be made clear to all patients undergoing such a procedure; (b) There ought to be some check/investigation post operation to determine (or to try and determine as best possible) whether air may have entered the blood stream during the operative procedure; (c) Patients undergoing this operation (which normally lasts between 2-3 hours) should be advised to stay in hospital as an in-patient for at least 24 hours, which would enable careful and extended monitoring of their condition and a swift and informed transfer, if necessary, to an acute care unit of a hospital in the event of a deterioration in their condition. ”

    Source location

    Gary Day · Prevention of Future Deaths report
    Page 3 · 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 post-operative checks for air embolism

    Wider context from the report

    “I am concerned that: (a) Any patient who elects to have an endoresection operation of an choroidal melanoma faces a risk (however small) of air embolism and therefore death. This must be made clear to all patients undergoing such a procedure; (b) There ought to be some check/investigation post operation to determine (or to try and determine as best possible) whether air may have entered the blood stream during the operative procedure; (c) Patients undergoing this operation (which normally lasts between 2-3 hours) should be advised to stay in hospital as an in-patient for at least 24 hours, which would enable careful and extended monitoring of their condition and a swift and informed transfer, if necessary, to an acute care unit of a hospital in the event of a deterioration in their condition. ”

    Source location

    Gary Day · 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

    Cease undertaking further endoresection procedures of this nature.

    Verbatim wording from the response

    “As we have been unable to establish the cause of the air embolus, the trust has elected to not undertake further procedures of this nature. We acknowledge your concern and if this procedure is performed at any time in the future we will ensure that patients are informed of the associated risk of death.”

    Source location

    2021-0107-Response-from-Moorfields-Eye-Hospital-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 14 April 2021

    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 Trust will not undertake further procedures because it cannot establish the cause of the air embolus.

    Verbatim wording from the response

    “As we have been unable to establish the cause of the air embolus, the trust has elected to not undertake further procedures of this nature. We acknowledge your concern and if this procedure is performed at any time in the future we will ensure that patients are informed of the associated risk of death.”

    Source location

    2021-0107-Response-from-Moorfields-Eye-Hospital-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 14 April 2021

    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 Trust cannot provide enhanced postoperative monitoring and intensive care support because it lacks the necessary facilities.

    Verbatim wording from the response

    “The trust does not have the facilities to undertake the enhanced level of monitoring that patients undergoing this procedure would require. As we have been unable to establish the cause of the air embolus, the trust has elected to not undertake further procedures of this nature. We acknowledge your concern”

    Source location

    2021-0107-Response-from-Moorfields-Eye-Hospital-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 14 April 2021

    Open published response

  3. Birmingham and Solihull

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026