Recipient

Moorfields Eye Hospital NHS Foundation Trust

First report 13 Apr 2021•Latest report 13 Apr 2021

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Moorfields Eye Hospital NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Apr2021
Inner North London
Concerns raised3
1. Failure to inform patients undergoing endoresection of choroidal melanoma of the risk of air embolism and death
2. Failure to advise patients undergoing endoresection of choroidal melanoma to remain hospital inpatients for at least 24 hours
3. Lack of post-operative checks for air embolism
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Cease undertaking further endoresection procedures of this nature.
  Stated completed
Respondent positions 2
1. Position
  The Trust will not undertake further procedures because it cannot establish the cause of the air embolus.
  Unable to act
1. Position
  The Trust cannot provide enhanced postoperative monitoring and intensive care support because it lacks the necessary facilities.
  Unable to act
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
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

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

Reports, concerns and published responses

Reports over time

Concerns raised3

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

Failure to advise patients undergoing endoresection of choroidal melanoma to remain hospital inpatients for at least 24 hours

Lack of post-operative checks for air embolism

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 1

Respondent positions 2