British Society Of Interventional Radiology

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First report 3 Mar 2016•Latest report 3 Mar 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from British Society Of Interventional Radiology linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. 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. The report was sent to British Society Of Interventional Radiology; 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 Society Of Interventional Radiology; 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026