Derryck Crocker

Dear Ms Goward, British Thoracic Society Regulation 28: Report to prevent futures deaths Mr Derryck Crocker We have been asked to respond to the Regulation 28 form which has been passed to us by the Royal College of Physicians, London. We are deeply sorry to hear of the sad death of Mr Crocker and we send our condolences to Mr Cracker's family. As the report notes, the occurrence of an air embolism is a rare but recognised complication that can occur following an invasive procedure. In the case of CT guided lung biopsy, radiology colleagues will be aware of the importance of timely and appropriate treatment, as will respiratory colleagues. We suggest that this would be suitable for a patient safety alert such as those issued by NHS England to ensure that there is a timely and appropriate response to such cases, with the intention of preventing future deaths. The British Thoracic Society will make a proposal to the NHSE Patient Safety Committee and will provide any advice and support requested of us. We have copied this letter to the Royal College of Physicians, London, the Royal College of Radiologists and the British Society of lnterventional Radiology.

Dear Norfolk Coroner team,

The Royal College of Physicians (RCP) notes the content of the Regulation 28 report for the prevention of future deaths related to the death of Derryck Lynn Crocker.

We send our sincere condolences to the family.

We recognise that air embolus is a serious but rare complication of invasive procedures.

For trainees in respiratory medicine their curriculum states related to lung biopsy: “Trainees must be able to outline the indications for these procedures and recognise the importance of valid consent, aseptic technique, safe use of analgesia and local anaesthetics, minimisation of patient discomfort, and requesting help when appropriate. For all practical procedures, the trainee must be able to recognise complications and respond appropriately if they arise, including calling for help from colleagues in other specialties when necessary”.

In addition, air embolus is a recognised complication of central line infection and all physician trainees at Internal Medicine Stage 1, with similar guidance in their curriculum.

We would support the British Thoracic Society recommendation of an NHS Patient Safety Alert to raise wider awareness.

Please confirm receipt of this email.

Kind regards,

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Dear Ms Goward, Further to your Prevention of Future Deaths Notice following the conclusion of your inquest (30th July 2024) into the death of Derryck Lynn Crocker who died on 10th May 2023, we like to extend our sympathy and condolences to the family and friends of Mr. Crocker. We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform.

Dear Dr Goward

Regulation 28: Report to prevent future deaths

Thank you for your letter of 1 August 2024 concerning the death of Derryck Crocker following an air embolism.

The Royal Society of Medicine is a membership organisation, including 55 specialist sections that provide an extensive programme of educational events to ensure doctors keep up to date in their respective fields. This puts us in an excellent position to provide ongoing education about the risks of air embolism and its management.

In response to Regulation 28, I can confirm the following actions:

• The Presidents of all the relevant specialist Sections at the RSM have been asked to add in the risks of air embolism and its management to any appropriate educational events for the coming year.
• The Patient Safety section, which is running its 14th annual event for those at medical school and junior doctors, will use its Patient Safety Summit on 14 November 2024 to elevate the profile of the risks of air embolism and the signs and symptoms that might be seen following any invasive procedure. This will be covered by a specialist in anaesthetics.

Dear Mrs Goward Regulation 28 Report to Prevent Deaths: Mr Derryck Lynn Crocker Matter of Concern: 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, and that air embolism is not something that is routinely taught as part of the training of doctors. Royal College of Surgeons of England response, on behalf of the Joint Committee on Surgical Training (JCST): Air embolism is something that is well recognised by those involved in Vascular lnterventional Radiology and lung biopsies i.e. those closely related to the procedures where it is likely to be complication of (e.g. those involved in obstetrics will be more aware and up to date with amniotic fluid embolism) but other specialties are likely to be much less familiar. In terms of specific surgical specialties, we would draw your attention to the following examples: Cardiothoracic surgery: There is a recognised association with air embolism during cardiothoracic surgery particularly involving cases where the cardiac chambers are opened and or cardiopulmonary bypass or mechanical circulatory support is used to support the patient's circulation. A knowledge of techniques to de-air the circulation, as well as the pathophysiology or complications of air embolism is covered in several areas within the curriculum. Neurosurgery: The risks of air embolism are regularly discussed with trainees whenever operating near the venous sinuses. The principal concern being large quantities of air entering the veins within the head and going to the heart causing haemodynamic instability In respect of the core surgical curriculum completed by all surgical trainees: irm@rcseng acuk

We have reviewed the MRCS examination (2013 updated 2018) & Core Surgical Curriculum (CST) (2017 and 2021) syllabus, and discussed this issue with colleagues who are instructors of the Advanced Trauma Life Support (A TLS) and Care of the Critically Ill Surgical Patient (CCrlSP) courses. Assessment and management of thromboembolism is part of the scope of the MRCS/CST curriculum and the part of the syllabus which involves placement/management of central line will have in general included considerations for complications such as air embolism. An understanding of the risks of anaesthesia and medical gases is generic to surgical training. We believe it to be a commonly asked question in the examination. There is a brief mention of it within ATLS. However, delivery of courses can vary and such a specialised complication/subject will not have been covered consistently. There isn't a CCrlSP scenario related to air embolism for the same reason. We will flag this within our governance mechanisms for ATLS and CCrlSP (A TLS steering group and CCrlSP clinical lead and working party) and will draw attention to the risk of air embolism with our membership through our regular communications. Thank you for drawing this to our attention.