Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0368, written 30 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2014 |
|---|---|
| Reference | 2014-0368 |
| Deceased | Monique Whitbread |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Monique Susanna WHITBREAD (died 25.03.14)
THIS REPORT IS BEING SENT TO:
1.
Consultant Bariatric Surgeon
University College Hospital
University College of London Hospitals NHS Trust
235 Euston Road
London NW1 2BU
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 1 April 2014, I commenced an investigation into the death of Monique
Whitbread, aged 49 years. The investigation concluded at the end of the
inquest on 23 July. The determination I made at inquest was that
Monique Whitbread died from a recognised complication of medical
treatment.
4
CIRCUMSTANCES OF THE DEATH
Ms Whitbread’s medical cause of death was:
1a pulmonary aspergillosis and sepsis;
1b intra abdominal complications related to bariatric procedures;
1c laparoscopic gastric bypass on 09.01.14 for obesity;
2 diabetes mellitus, hypertension.
1
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
Ms Whitbread had a body mass index of above 50 and was referred for
bariatric surgery. She also had a hernia. Her surgical options were:
- gastric band
- sleeve gastrectomy
- gastric bypass.
You performed a gastric bypass on 9 January 2014. At operation, you
freed a plug of omental fat to perform the bypass, but it seems that this
later allowed Ms Whitbread’s hernia to strangulate, and she died
ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve
gastrectomy rather than a gastric bypass on those patients who have a
hernia. Although the surgery is not necessarily quite as effective, you
believe it to be safer in this situation.
It seems from your evidence that it would be helpful to disseminate your
experience and observations nationally.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 29 September 2014. I, the coroner, may extend
the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
2
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
brother of Monique Whitbread
I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
30.07.14
3
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