A retired company director may have lived longer were it not for a "lack of understanding" of a rare medical complication which arose following an operation, an inquest has found.
Derryck Crocker, from Lowestoft, died at the age of 77 on May 10, 2023, a week after undergoing a lung biopsy operation.
An inquest into his death heard that following his procedure he developed a rare complication called air embolism, a condition whereby air bubbles infiltrate the bloodstream.
However, the court heard that signs of this were not initially recognised by NHS staff and his condition deteriorated.
Mr Crocker underwent his lung biopsy on May 3 at 1pm, after previous investigations had shown a suspicious mass.
On signing consent for the procedure, several risks were explained to him, including bleeding, infection and pneumonia. However, air embolism was not one of these.
After the procedure, he became semi-unresponsive and a resuscitation team was called in.
A CT scan was done at 1.29pm which did not find evidence of air embolism.
However, it was not until several hours later, when Mr Crocker had a seizure and cardiac arrest that treatment for an embolism took place.
On May 7, end-of-life care was commenced and he died three days later.
(Image: Newsquest)
His death has sparked area coroner Samantha Goward to warn that future deaths could happen if medical staff are not better trained to notice signs of the condition.
In a report she wrote: "I heard evidence that there is a lack of understanding of the signs and symptoms of air embolism and this risk of this following any invasive treatment.
"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."
Mrs Goward's report has been sent to presidents of several leading medical colleges, emphasising the importance of improving awareness of the risk.
It has been sent to:
The Royal College of Emergency Medicine
The Royal Society of Medicine
The Royal College of Physicians
The Royal College of Surgeons
The Royal College of Anaesthetists.
At the end of the inquest, Mrs Goward concluded that Mr Crocker had died "due to the delayed recognition and treatment of a rare, but recognised complication of a lung biopsy".
Hospital's response
The James Paget University Hospital in Gorleston, where Mr Crocker died, welcomed the coroner's calls.
A spokesman said: "Our condolences are with Mr Crocker's family.
"As a trust, we have already taken action to improve awareness and training in the diagnosis and management of air embolism.
"We would support the development of best practice guidelines nationally to help enhance patient care in this area.
What is air embolism?
Air embolism, also known as gas embolism, is a medical condition which occurs when air enters a vein or artery and blocks it.
It can happen when air passes directly from the atmosphere into blood vessels, which can occur inadvertently during surgery.
However, this is extremely rare.
The condition has received high-profile attention in the past year due to its prevalence in the trial of nurse Lucy Letby.
Letby, of Hereford, was found guilty of murdering seven babies and attempting to kill six others while working at the Countess of Chester Hospital in 2015 and 2016.
A jury who convicted Letby was told babies who died in her care had developed embolism after being deliberately injected with air by the neonatal nurse.
In Mr Crocker's case, the complication occurred naturally during the operation, but was not treated soon enough to prevent his death.
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