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recurance

Derryck Crocker

30 Jul 2024 · Coroner Samantha Goward · Norfolk

The coroner's concerns

  1. 1. lack of understanding of air embolism signs and symptoms

    “I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure. I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors. While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly.”
  2. 2. lack of knowledge causing underreporting of air embolism cases

    “I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr [name redacted] death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness.”
  3. 3. delayed recognition of air embolism

    “I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely.”
  4. 4. lack of national awareness of air embolism

    “I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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