Recipient

The Royal Society Of Medicine

First report 1 Aug 2024•Latest report 1 Aug 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Registered charity. 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: 4
Stated actions: 2

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

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from The Royal Society Of Medicine linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Aug2024
Norfolk
Concerns raised5
1. Failure to recognise and report air embolism cases
2. Delays in recognising air embolism
3. Delays in treating air embolism
1. Lack of nationally consistent air embolism awareness training across relevant specialties
2. Lack of knowledge and training on recognising air embolism following invasive procedures
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Add air embolism risks and management to appropriate educational events across relevant specialist sections during the coming year.
  Stated planned
2. 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.
  Stated planned
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.

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 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
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
Page 1 · response
Published 8 August 2024
Open published response
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
Page 1 · response
Published 8 August 2024
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 raised5

Failure to recognise and report air embolism cases

Delays in recognising air embolism

Delays in treating air embolism

Lack of nationally consistent air embolism awareness training across relevant specialties

Lack of knowledge and training on recognising air embolism following invasive procedures

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

Actions described in response 2