What happened?

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• The IABP was inserted intraoperatively, the following day, the IABP console began intermittently alarming indicating a possible gas leak.

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• This was escalated and was reviewed at the bedside by the perfusionist. Standard checks were conducted by the perfusionist, and no additional evidence of a significant leak/ rupture was noted. A second perfusionist reviewed later that evening.

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• The perfusionist did raise with the clinical team whether the IABP was still required.

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• A second perfusionist also conducted trouble shooting and swapped out the console in case that was the cause. This appeared to resolve the alarm issue at the time.

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• Overnight, this IABP console continued to alarm.

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• During morning review with perfusion, surgical and anaesthetic teams, blood was noted in the line at this stage for the first time, indicating possible rupture of the IABP balloon, and a decision was taken to remove the IABP.

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• Removal of the IAPB was noted to be straightforward. Nil concerns noted at the time of removal. Pressure applied to the area following removal. The balloon tip was discarded and not inspected.

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What was expected?

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• Clear documentation of all care and intervention delivered to the patient.

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Why was there a difference?

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• Although troubleshooting appears to have been undertaken appropriately (console swap, inspection, review by on‑call perfusion), there is no clear standardised protocol for managing recurrent IABP alarms.

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• Perfusionists do not document actions in the patient’s clinical notes (Cerner electronic record) or any other location, which limited visibility of troubleshooting, communication between the multi-professional team, and possibly reduced continuity of care.