Prevention of Future Deaths Report – Gary Day

Summary

Gary Day had 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.

Gary Day died less than 24 hours after the operation as a result of an air embolism. In the Coroner’s matters of concern, it was noted he was not advised beforehand of the potential risk of death, there was no check for an air embolism after the operation and he probably should have been kept in hospital overnight for observation.

The report was sent to Moorfields Eye Hospital but has safety implications for all Trusts performing this procedure.

Content

Evidence showed 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.

3 Mr Day 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.

The Assistant Coroner listed his concerns and recommendations as follows:

(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.