MOORFIELDS eye hospital is under investigation by England’s health watchdog following the death of a patient.

In a report published on Wednesday by the Care Quality Commission, it stated that a “focused” inspection of Moorfields Eye Hospital NHS Foundation Trust was carried out in September after two separate incidents, including the death of a patient.

A 57-year-old man died from an “air embolism” – air in his blood – following eye surgery at the City Road hospital just before Christmas 2020.

A CQC spokesman said: “We are currently in the process of making initial enquiries to establish whether there is reasonable suspicion that a criminal offence has been committed. Those enquiries are ongoing.”

Its report stated: “The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken.

“As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.”

Last year Inner North London coroner Edwin Buckett filed a Prevention of Future Deaths (PFD) report over the death, calling for improved systems at the hospital and nationally.

The patient had left Moorfields after an endoresection procedure but died in the Royal London Hospital – 19 hours after the operation. It was heard the Royal London was unaware of the clinical procedure undertaken just hours earlier when he was admitted as hospital staff did not have “immediate access” to his medical notes.

All hospitals offering such surgery have now been told they must advise patients they could die. They must also check for air in the blood after surgery and keep them in the hospital for 24 hours to monitor them.

Following the patient’s death, the trust removed the surgical procedure from its list of treatments and carried out its own investigation.

In a letter written to Mr Buckett last year, it said: “The trust does not have the facilities to undertake the enhanced level of monitoring that patients undergoing this procedure would require. As we have been unable to establish the cause of the air embolus, the trust has elected to not undertake further procedures of this nature.”

The CQC investigation also looked into the culture of surgery theatres at Moorfields after it “received concerns about the behaviours of some staff working in the operating theatres”.

It found that “although the trust had taken some action, the problems continued, and we were unsure if the action taken by the trust was bringing about the necessary improvements”.

It called on the trust to “improve the culture in theatres, with attention to supporting colleagues to report when they have been bullied or harassed by other colleagues” and told it to strengthen its whistleblowing scheme, named the “freedom to speak up guardian programme”.

The report added: “Our rating of services stayed the same because this was a focused inspection and we did not inspect all domains or all key lines of the domain we inspected. Surgery and well-led remain rated Good. Safe, caring, responsive and well-led remain rated as good, and effective remains rated outstanding.”

It also said that since the patient’s death, the hospital has overseen “significant changes at executive level” and cited the trust was “undergoing a period of transformation”. In 2026, Moorfields is due to move to a purpose-built new site in St Pancras named Oriel.

A spokesman for Moorfields said: “We continue to offer our sincere condolences to the patient’s family, and our thoughts remain with them. We have reviewed and updated our processes in light of our own investigation and the Coroner’s ­recommen­­dations.

“Following this incident, we have shared the issue with other trusts and the international ophthalmology community.”