T2025-01 Death of a patient as a result of anaesthesia administered during magnetic resonance imaging in January 2025

Magnetic resonance imaging (MRI) was performed under sedation on a middle-aged patient at a private medical centre in Kuopio on 2 January 2025. The patient’s condition deteriorated during the scan and they became lifeless. The patient was resuscitated, but later died in a hospital.

The patient had sought treatment at the medical centre due to worsening shoulder pain. An MRI had previously been attempted on the patient without sedation, but this was unsuccessful. The anaesthesiologist suggested performing an MRI under sedation on the same day because the patient suffered from claustrophobia. The patient could have waited for an MRI scan performed at Kuopio University Hospital, for which an orthopaedist had previously provided a referral.

The procedure deviated from the national recommendations because the medical centre in question did not have readiness to safely perform MRI scans under sedation. The amount of anaesthetic medication administered to the patient resulted in a situation equivalent to general anaesthesia rather than sedation. The oxygen flow administered through an oxygen mask was also too low, which contributed to causing respiratory depression. An MRI-compatible monitor required to monitor the patient’s basic vital signs was not available and the patient’s deteriorating condition was not noticed in time.

The imaging unit was not prepared to handle an emergency situation. The resuscitation and patient transfer equipment had to be retrieved from other spaces in the medical centre, which delayed the start of life support. No regular training for resuscitation and emergency situations had been organised for imaging unit staff.

The investigation found that the medical centre’s self-supervision plan and risk management were inadequate. The agreement between the medical centre and the company providing anaesthesia services was also general in terms of specifying responsibilities and roles.

Finland does not have comprehensive and up-to-date national data concerning non-operating room anaesthesia (NORA). This makes it impossible for supervisory authorities to form an overall picture of the safety, quality and consistency of services.

The Ministry of Social Affairs and Health has not provided sufficient guidance for interpreting the Act on the Supervision of Healthcare and Social Welfare Services. The supervisory authorities have performed supervisory work without comprehensive instructions. As a result, service providers have not received adequate guidance on the implementation of self-supervision and application of the Act in practice.

Three recommendations were issued in the investigation. The Safety Investigation Authority recommends that

1. The Ministry of Social Affairs and Health, in cooperation with the Finnish Supervisory Agency, ensure the development of self-supervision in a way that provides clear and uniform instructions for the practical implementation and evaluation of self-supervision. [2026-S4]
2. The Ministry of Social Affairs and Health ensure that national minimum requirements and safe implementation methods are specified for NORA activities. [2026-S5]
3. The Finnish Institute for Health and Welfare (THL) develop systematic data collection concerning private health care procedures in order to provide a comprehensive picture of them to meet the needs of different authorities. [2026-S6]