Gary Day
PFD Report
All Responded
Ref: 2021-0107
All 1 response received
· Deadline: 8 Jun 2021
Coroner's Concerns (AI summary)
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.
View full coroner's concerns
Evidence was given by medical staff at Moorfields Eye Hospital that:
1. Mr Day was not informed that there was any risk of death from the surgery he elected to have, even though there is a risk of air embolus, and therefore death, from this procedure. The Consent Form he signed did not make any reference to a risk of death;
2. There was no check carried out for air embolus after the operation;
3. There was confusion between medical staff as to whether or not Mr Day was to be kept in for an over-night stay in hospital. As it turned out, he was not advised to stay in hospital over-night and was allowed to leave 3 hours after the operation had concluded. This meant that when he was taken to the Royal London Hospital on the evening of the 15th December, 2020 clinical staff in hospital did not have immediate access to any medical notes concerning his earlier procedure.
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.
1. Mr Day was not informed that there was any risk of death from the surgery he elected to have, even though there is a risk of air embolus, and therefore death, from this procedure. The Consent Form he signed did not make any reference to a risk of death;
2. There was no check carried out for air embolus after the operation;
3. There was confusion between medical staff as to whether or not Mr Day was to be kept in for an over-night stay in hospital. As it turned out, he was not advised to stay in hospital over-night and was allowed to leave 3 hours after the operation had concluded. This meant that when he was taken to the Royal London Hospital on the evening of the 15th December, 2020 clinical staff in hospital did not have immediate access to any medical notes concerning his earlier procedure.
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.
Responses
Action Taken
Moorfields Eye Hospital NHS Foundation Trust has completed an internal investigation, shared the report with the next of kin, and elected to not undertake further procedures of this nature due to lack of facilities for enhanced monitoring. (AI summary)
Moorfields Eye Hospital NHS Foundation Trust has completed an internal investigation, shared the report with the next of kin, and elected to not undertake further procedures of this nature due to lack of facilities for enhanced monitoring. (AI summary)
View full response
Dear Mr Buckett
Regulation 28 Prevention of Future Deaths (PFD) report: Gary Day (died 16 December 2020)
I am writing in response to the PFD report that you issued on 13 April 2021, following your investigation into the death of Mr Gary Day from an air embolism. This followed a surgical procedure (endoresection of a choroidal melanoma) undertaken on 15 December 2020 at Moorfields Eye Hospital. We have completed our internal investigation and have shared the report with
next of kin, and her family. Our investigation identified a number of opportunities for improvement and shared learning; implementation of the agreed actions will be closely monitored via our internal governance processes. We have also shared our completed investigation report with the Care Quality Commission and our lead commissioner and commissioning support unit. Our internal investigation considered potential air sources as possible, or likely sources of air entry, based on precautions taken and/or the volume of air present. However, it was not possible to conclude exactly how air was able to enter the patient’s circulatory system. It is confirmed, because of the existence of the recording of the procedure, that air did not enter the patient’s circulation
visibly via the eye, as this would have been observed as a significant volume of air bubbles. However, only occasional small singular bubbles were seen either during surgery, or on subsequent review of a recording of the procedure. There are four explanations for the subsequent development of air embolus that have not been excluded or considered in detail as a possibility during the course of this investigation. Further consideration of these possibilities is warranted, but this will be done as part of a larger piece of research that considers the worldwide prevalence of similar cases. The four possible causes of air embolus have been identified as: Heavy liquid; Heavy liquid interaction with another substance (e.g. silicone oil); Patient physical or medical conditions that makes a patient more or less disposed to the risk of air embolus; and A previously unrecognised source.
Following careful consideration of your concerns, in light of our investigation findings and consideration of information shared by endoresection surgeons from around the world, our responses are set out below:
Concern (a) Any patient who elects to have an endoresection operation of a 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.
Trust 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.
Concern (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.
Trust 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
and if this procedure is performed at any time in the future we will ensure that it is undertaken in a facility that can provide the post-operative monitoring and intensive care support required.
Concern (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.
Trust response As described above, the trust does not have the facilities to undertake the enhanced level of monitoring that patient’s 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 and if this procedure is performed at any time in the future we will ensure that it is undertaken in a facility that can provide the post- operative monitoring and intensive care support required.
I hope this response is satisfactory and we would be happy to answer any further queries.
Regulation 28 Prevention of Future Deaths (PFD) report: Gary Day (died 16 December 2020)
I am writing in response to the PFD report that you issued on 13 April 2021, following your investigation into the death of Mr Gary Day from an air embolism. This followed a surgical procedure (endoresection of a choroidal melanoma) undertaken on 15 December 2020 at Moorfields Eye Hospital. We have completed our internal investigation and have shared the report with
next of kin, and her family. Our investigation identified a number of opportunities for improvement and shared learning; implementation of the agreed actions will be closely monitored via our internal governance processes. We have also shared our completed investigation report with the Care Quality Commission and our lead commissioner and commissioning support unit. Our internal investigation considered potential air sources as possible, or likely sources of air entry, based on precautions taken and/or the volume of air present. However, it was not possible to conclude exactly how air was able to enter the patient’s circulatory system. It is confirmed, because of the existence of the recording of the procedure, that air did not enter the patient’s circulation
visibly via the eye, as this would have been observed as a significant volume of air bubbles. However, only occasional small singular bubbles were seen either during surgery, or on subsequent review of a recording of the procedure. There are four explanations for the subsequent development of air embolus that have not been excluded or considered in detail as a possibility during the course of this investigation. Further consideration of these possibilities is warranted, but this will be done as part of a larger piece of research that considers the worldwide prevalence of similar cases. The four possible causes of air embolus have been identified as: Heavy liquid; Heavy liquid interaction with another substance (e.g. silicone oil); Patient physical or medical conditions that makes a patient more or less disposed to the risk of air embolus; and A previously unrecognised source.
Following careful consideration of your concerns, in light of our investigation findings and consideration of information shared by endoresection surgeons from around the world, our responses are set out below:
Concern (a) Any patient who elects to have an endoresection operation of a 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.
Trust 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.
Concern (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.
Trust 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
and if this procedure is performed at any time in the future we will ensure that it is undertaken in a facility that can provide the post-operative monitoring and intensive care support required.
Concern (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.
Trust response As described above, the trust does not have the facilities to undertake the enhanced level of monitoring that patient’s 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 and if this procedure is performed at any time in the future we will ensure that it is undertaken in a facility that can provide the post- operative monitoring and intensive care support required.
I hope this response is satisfactory and we would be happy to answer any further queries.
Sent To
- Moorfields Eye Hospital NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Jun 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 24th December, 2020 Senior Coroner Hassell began an investigation into the death of Gary Day who died aged 57, on the 16th December, 2020 at the Royal London Hospital, Whitechapel Road, London, E1.
The investigation concluded at the end of the inquest on 12th April, 2021 conducted by myself, Assistant Coroner Edwin Buckett.
I made a determination at inquest that the deceased died as a result of air embolism which was caused by an elective endoresection operation and/or associated operative treatment carried out at Moorfields Eye Hospital on the 15th December, 2020.
The investigation concluded at the end of the inquest on 12th April, 2021 conducted by myself, Assistant Coroner Edwin Buckett.
I made a determination at inquest that the deceased died as a result of air embolism which was caused by an elective endoresection operation and/or associated operative treatment carried out at Moorfields Eye Hospital on the 15th December, 2020.
Circumstances of the Death
Gary Day has a choroidal melanoma of the left eye. After discussing his treatment options with clinicians at Moorfields Eye Hospital, he elected to have that melanoma removed by an endoresection procedure at the hospital. On the 15th December, 2020 the operation, which took around 3 hours, was completed at about 4pm. Pressurised air was not used in the operation. Heavy oil was used as a means of attaching the retina. Thereafter, Mr Day left the hospital at around 7.15pm, walking to a waiting taxi which took him home. Later that evening, he became unwell. Between 9-10pm, he was taken by ambulance to the Royal London Hospital and admitted to the critical care unit. Whilst in hospital a CT pulmonary angiogram was reviewed by a Consultant Radiologist which was suggestive of a large volume of air embolus. Mr Day became severely unwell and died at about 10.50am on the 16th December, 2020, some 19 hours after the operation. The post mortem examination of Mr Day concluded that his death was caused by air embolus which in turn had been caused by the endoresection operation.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Transfusion Committees and Tranexamic Acid - England
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Tranexamic Acid - Scotland, Wales and NI
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Care and discharge planning
Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Laming Inquiry
Care and discharge planning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.