Ronald Bentley
3 Mar 2016 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. air embolism
“During the inquest the Consultant [name redacted], gave evidence that before the procedure it had not occurred to him that in performing the procedure with conscious sedation there is a risk that if the patient breathes deeply at the 4 or so points when the sheath is open air could enter the vascular system”
2. air embolism during conscious sedation
“the Coroner's concern is that unless this risk is widely known, and safeguards introduced as a consequence, there continues to be a risk that patients at other Cardiac Centres could suffer the same complication”