Concerns raised 5 Failure to recognise and report air embolism cases View source Delays in recognising air embolism View source Delays in treating air embolism View source Lack of nationally consistent air embolism awareness training across relevant specialties View source Lack of knowledge and training on recognising air embolism following invasive procedures View source See 2 more concerns
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
Add air embolism risks and management to appropriate educational events across relevant specialist sections during the coming year.
View source
Action
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.
View source
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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.
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× 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 The Royal Society Of Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and report air embolism cases
Wider context from the report “2. I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr Crocker’s death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness.
” 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 The Royal Society Of Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 The Royal Society Of Medicine; that does not assign responsibility.
PFD Monitor interpretation Delays in treating air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 The Royal Society Of Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally consistent air embolism awareness training across relevant specialties
Wider context from the report “4. I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally .
” 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 The Royal Society Of Medicine; that does not assign responsibility.
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.
” 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 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
Open published response
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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 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
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations