Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0317, written 4 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Sep 2023 |
|---|---|
| Reference | 2023-0317 |
| Deceased | Emma Morrissey |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Regenesis Health Travel Limited 1 CORONER I am Jacqueline DEVONISH, Senior Coroner for the coroner area of Cheshire 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 28 July 2022 I commenced an investigation into the death of Emma Louise MORRISSEY aged 44. The investigation concluded at the end of the inquest on 31 August 2023. The conclusion of the inquest was that: Narrative Conclusion - Died as a result of a massive uncontrolled bleed caused by an instrument perforation within the abdomen during surgery. 4 CIRCUMSTANCES OF THE DEATH On 06 July 2022 Emma Louise Morrissey flew to Turkey's private Termessos Hospital in Antalya for gastric sleeve surgery. Arrangements were made through a health tourism company Regenisis. On 07 July 2022 Emma was operated. The surgeon perforated her abdomen with an instrument. The area was packed to stem the bleed but no platelets for blood clotting were administered causing continued bleeding and her sad death on 08 July 2022 at 12: 45 hours. 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. The health tourism company Regenesis UK relied upon patient self declaration of health and made no independent enquiries to satisfy themselves that Emma was fit for the gastric sleeve procedure before making the arrangement for her to have surgery at the Termessos Hospital, Antalya in Turkey. 2. The series of health related pre-assessment questions asked before referral to the private hospital in Turkey were unclear, as there was no evidence of a standard form produced by a medically trained source for the referring staff to refer to. The questions did not include an enquiry about family history of medical conditions such as cardiac related relevant to Emma. Regulation 28 - After Inquest Document Template Updated 30/07/2021 3. There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation. 4. The embalming process for repatriation from Turkey to the UK was inadequate due to there being no evidence of fluid perfused to the great vessels, leaving Emma's body at risk of infection during transit. This presented a risk of decomposition as well as a health risk to the professionals receiving her body in the UK. 5. The surgery note provided to Regenesis stated that the sleeve gastrectomy operation was not completed following the intra-abdominal bleed in the omentum. The UK post mortem confirms that the surgery had been completed and that the site of the bleed was the lieno-renal ligament and not the omentum. The lieno-regal ligament site had been packed to stem the bleed during the operation and was present at post mortem. 5. The cause of death reported in Turkey was natural. It was recorded as la, Cardigenic Shock, due to lb. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 October 30, 2023. 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 Warrington Borough Council Private Termessos Hastanesi I have also sent it to Foreign, Commonwealth & Development Office who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. Regulation 28 - After Inquest Document Template Updated 30/07/2021 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 Dated: 04/09/2023 Jacqueline DEVONISH Senior Coroner for Cheshire Regulation 28 - After Inquest Document Template Updated 30/07/2021
1 response 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.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU Ms Jacqueline Devonish HM Senior Coroner The Cheshire Coroner's Service East and West Annexes Town Hall Sankey Street Warrington Cheshire WA1 1UH 15 November 2023 Dear Ms Devonish, Thank you for your letter of 4 September 2023 to the Secretary of State for Health and Social Care about the death of Emma Louise Morrissey. I am replying as Minister for Mental Health and Women’s Health Strategy. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Ms Morrissey’s death. I appreciate how distressing her unexpected death must be for family and loved ones, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to her in order to prevent future deaths. On receipt of your report, the UK Government expressed our concerns to the Turkish Ministry of Health, given the circumstances surrounding Ms Morrissey’s death. More broadly, my officials are investigating the issues surrounding global medical tourism. Our efforts to understand the consequences of international health tourism are global, but we have a strong interest in Türkiye given it is a key destination for healthcare tourism for UK nationals. The Department has been consulting with the Foreign, Commonwealth and Development Office, NHS England, the Devolved Governments and other relevant stakeholders to obtain a better picture of the impact of medical tourism on patient safety and the NHS. My officials will also be visiting Türkiye shortly to meet with their counterparts. The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future. Specifically, I have noted in your report the lack of standard pre-assessment questions provided to Ms Morrissey in Türkiye. This meant the clinicians failed to address family medical history and her associated cardiac risk. We remain aware countries providing healthcare tourism often conduct pre-assessment checks that may not match UK regulatory standards and we want to encourage all providers treating UK nationals to meet international best practices on pre-operative procedures whenever possible. Such transparency and standardisation are important to reduce potential risks to patients and improve patient care in the UK and overseas. I also noted your remarks on Ms Morrissey's inadequate embalming prior to the repatriation of her body. My officials will ensure that Turkish authorities understand the public health risks when bodies are not appropriately embalmed and lobby that further action is taken to ensure that there is no repeat of what happened to Ms Morrissey. The Government is considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks ahead of surgery and understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home. I hope this response is helpful in setting out how seriously the UK Government is taking the issues raised in your report. Yours sincerely, MARIA CAULFIELD
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