Table 5 Deaths following a cardiorespiratory complication.

Patient	Age (years)	ASA score	Indication	Monitoring	Sedation	Comments
1	74	2	CBD stones	Oximetry	Midazolam 8 mg	Cardiac arrest during procedure. Resuscitation failed. Postmortem revealed severe coronary artery disease
				BP monitoring	Pethidine 50 mg
2	75	3	Jaundice secondary to hilar mass	Oximetry	Midazolam 2 mg	Pre‐existing chronic obstructive airways disease with low oxygen saturations before ERCP. Developed right basal pneumonia after the procedure and died 2 days later
				BP monitoring	Pethidine 50 mg
				ECG monitoring
3	73	2	CBD stone with cholangitis	Oximetry	Midazolam and pethidine; dose unrecorded	Pre‐existing cardiac impairment and chronic obstructive airways disease. Deterioration following ERCP with signs of heart failure. Transferred to ITU. Died 27 days after the procedure
4	88	2	Jaundice secondary to pancreatic cancer	Oximetry	Midazolam 1.5 mg	Attended as day‐case. Became hypoxic and unresponsive after sedation and intubation. Procedure had to be abandoned and patient admitted. Decision made to palliate. Died 12 days later
					Pethidine 25 mg

ASA, American Society of Anesthesiology; BP, blood pressure; CBD, common bile duct; ECG, electrocardiogram; ERCP,endoscopic retrograde cholangio‐pancreatography.