Gary Day
13 Apr 2021 · Coroner Edwin Buckett · Inner North London
The coroner's concerns
1. risk of air embolus and death
“Mr [name redacted] 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. lack of post-operative air embolus check
“There was no check carried out for air embolus after the operation”
3. premature discharge after choroidal melanoma surgery
“There was confusion between medical staff as to whether or not Mr [name redacted] 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 2 was allowed to leave 3 hours after the operation had concluded”
4. risk communication failure for choroidal melanoma endoresection
“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”
5. absence of post-operative air embolus investigation
“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”
6. inadequate post-operative monitoring period
“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”