“Evidence was given by medical staff at Moorfields Eye Hospital that: 1”
Dated 13 Apr 2021, from the coroner for Inner North London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 8 Jun 2021.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated13 Apr 2021
- Deadline8 Jun 2021
- Published on judiciary.uk14 Apr 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Moorfields Eye Hospital NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2021. |
The 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 2 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2021-0107
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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