6 Nov 2019 Stuart Clarke · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Lack of national referral guidelines for patients with known valvular disease View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Contact members and ask them to review local referral pathways to expedite TAVI treatment and prevent delays.
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Stuart Clarke · 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
Stuart Clarke presented with breathlessness in February 2018 and underwent a TAVI procedure on 25 June 2019 after a prolonged pathway to treatment. He did not recover following the procedure and died at Wythenshawe Hospital on 27 June 2019. The principal concern was the absence of national guidelines for referral between primary, secondary and tertiary care for patients with known valvular disease, alongside concern about the timeliness of intervention.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Cardiovascular Intervention Society; that does not assign responsibility.
PFD Monitor interpretation Lack of national referral guidelines for patients with known valvular disease
Wider context from the report “However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valvular disease .
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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 Contact members and ask them to review local referral pathways to expedite TAVI treatment and prevent delays.
Verbatim wording from the response “BCIS would support the Department of Health and NHS England in moves to ensure that there is adequate capacity for TAVI candidates to be seen, investigated and treated without undue delay. In addition, we will contact our members to ask them to review local referral pathways to expedite treatment and prevent delays.” Source location 2019-0366-Response-from-BCIS_Redacted
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3 Mar 2016 Ronald Reginald BENTLEY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to introduce safeguards against air entry into the vascular system during procedures with conscious sedation View source Lack of widespread awareness of air-entry risk during procedures with conscious sedation View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Circulated the report to BCIS members through its official newsletter.
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Action
Passed report details to the British Heart Rhythm Society for onward circulation to electrophysiology colleagues.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Cardiovascular Intervention Society; that does not assign responsibility.
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 .
” 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 British Cardiovascular Intervention Society; that does not assign responsibility.
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.
” Open source report
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations