13 Apr 2021 Gary Day · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to inform patients undergoing endoresection of choroidal melanoma of the risk of air embolism and death View source Failure to advise patients undergoing endoresection of choroidal melanoma to remain hospital inpatients for at least 24 hours View source Lack of post-operative checks for air embolism 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
Cease undertaking further endoresection procedures of this nature.
View source
×
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. The report was sent to Moorfields Eye Hospital NHS Foundation Trust; that does not assign responsibility.
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.
” 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 Moorfields Eye Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise patients undergoing endoresection of choroidal melanoma to remain hospital inpatients for at least 24 hours
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.
” 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 Moorfields Eye Hospital NHS Foundation Trust; that does not assign responsibility.
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.
” 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
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
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
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations