Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0260, written 31 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2020 |
|---|---|
| Reference | 2020-0260 |
| Deceased | Renee Brooks |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) British Association of Aesthetic & Plastic Surgeons (2) British Association of Plastic, Reconstructive & Aesthetic Surgeons (3) National Institute for Care Excellence 1 CORONER I am James Bennett Area Coroner for Birmingham and Solihull. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 10/09/2019 I commenced an investigation into the death of Renee Simone Brooks. The investigation concluded at the end of an inquest on 14th January 2020. The Conclusion of the inquest was that she died from a recognised but rare complication (fat embolism syndrome) of a necessary procedure, contributed to by pre-existing cardiac issues. 4 CIRCUMSTANCES OF THE DEATH Mrs Brooks had debilitating lipoedema from the waist down and in her upper limbs, causing significant mobility impairment and pain. Her BMI was 46.1. She underwent rehabilitation and functional liposuction procedures in June, July and August 2018 and January 2019. These procedures were uneventful, she recovered well, and benefited from an improvement in her quality of life. On 29 August 2019 she underwent what was intended to be the final procedure on her legs. The risks, including fat embolism syndrome, were considered and consented to. The risk of mortality was considered low. The procedure took about 4 hours and was performed as planned. At the end of the procedure she suddenly went into cardiac arrest and after about 7 minutes was resuscitated and taken to Birmingham Heartlands Hospital. She remained very poorly and despite maximum treatment died on 30 August 2019. Post- mortem tests revealed she had a pre-existing significantly enlarged heart and fat embolisms were found in her lungs. Having heard evidence from the pathologist and her treating clinicians, the Coroner determined the medical cause of death to be: 1a MULTIPLE ORGAN FAILURE (PERI-OPERATIVE CARDIAC ARREST) 1b FAT EMBOLISM SYNDROME. 1c LIPOEDEMA (LARGE VOLUME LIPOSUCTION PROCEDURE) 2. COR PULMONALE. OBESITY CARDIOMYOPATHY. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from Clinical Director, and about the absence of UK guidance relating to indications for safe practice. In particular, in relation to: (a) - investigation lead for Spire Parkway Hospital. All expressed concern - consultant plastic and reconstruction surgeon, – Spire’s Group the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS. My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. 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 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 27th March 2020. 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 Chief Coroner and to the following Interested Persons: (1) The next of kin. (2) Spire Parkway Hospital. (3) , consultant plastic and reconstructive surgeon. I have also sent it to Dr Lipo surgeon and aesthetic doctor, who may find it useful or of interest. – Regional Medical Examiner, NHS England, and Dr , VASER 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 find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 31/01/2020 Signature James Bennett Area Coroner Birmingham and Solihull
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
7th March 2020 James Bennett Area Coroner Birmingham and Solihull The Corner’s Court 50 Newton Street Birmingham, B4 6E Dear Mr Bennett, Re: Renee Brooks – Report to Prevent Future Deaths We write in response to your Regulation 28 Report to prevent further deaths in relation to liposuction and the treatment of lipoedema. As a result of this request, both associations (BAPRAS & BAAPS) have agreed to work in partnership to create guidelines for the use of liposuction in the UK. We recognise the importance of making the distinction between liposuction for the treatment of lipoedema and liposuction for purely cosmetic reasons but feel that we should create combined guidelines for the safe use of liposuction in all surgical procedures. We consider this to be particularly important as some commercial organisations have drawn up their own guidelines which appear to aim to control the use of the technique in an ill-informed manner. A definitive and all-encompassing set of guidelines will ensure that the distinction between the two types of procedures is readily apparent. In order to create the guidelines, we have set up a joint BAAPS & BAPRAS expert panel. This panel will include invited expert members of both surgical associations, a member of the Association of Anaesthetists and any other relevant stakeholders that the co-chairs believe to be appropriate. Their report is intended to cover not only the specifics of the procedure but also the level of hospital support required, any pre-assessment needs and the potential need for a multi-disciplinary team (MDT) meeting for lipoedema patients. It is hoped that we can produce this report within the next six months and that it will be adopted by the wider sector, including those practitioners who are not members of our associations. The majority of liposuction in the UK is likely to be carried out by such practitioners and so we intend to submit these guidelines to the CQC for their use in the inspection of premises involved in liposuction. We will forward the guidelines for your inspection prior to publication. Yours sincerely, Mr President of BAAPS MD FRCS(Plast) Mr President of BAPRAS FRCS(Plast)
18 March 2019 James Bennett HM Senior Coroner The Coroner's Court 50 Newton Street Birmingham B4 6NE Via email: Our ref: Dear Mr Bennett, I write in response to your report, dated Friday 31 January 2020, regarding the death of Mrs Renee Simone Brooks. We have considered the circumstances surrounding Mrs Brooks’s death, and your that there is an absence of UK guidance relating to indications for safe practice for lipoedema-related liposuction. In August 2017 NICE published interventional procedures (IP) guidance on liposuction for chronic lymphoedema (IPG588), which currently recommends the following: 1.1 Current evidence on the safety and efficacy of liposuction for chronic lymphoedema is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit. 1.2 Patient selection should only be done by a multidisciplinary team as part of a lymphoedema service. However, we have not published guidance on the use of liposuction for the specific condition of chronic lipoedema. NICE IP guidance makes recommendations on the conditions for the safe use of a procedure in the NHS, based on the available evidence relating to safety and efficacy. The recommendations specify the type of arrangements that should be made for consent, audit and clinical governance. In view of the safety concerns raised by this case, the IP team will consider whether: • the current recommendations in relation to the safety and efficacy of liposuction for chronic lymphoedema should be updated to allow the guidance to provide additional explicit detail on safety concerns. In the meantime, our website (www.nice.org.uk/ipg588) now explains that “We are considering whether we need to update this guidance in response to safety concerns” and the webpage will be updated with the outcome of these considerations, in due course. • new IP guidance should be produced specifically relating to the use of liposuction in the treatment of chronic lipoedema. As part of any future guidance development, the IP team would consult with specialist societies such as the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Yours sincerely, Sir Chief Executive
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