Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0330, written 13 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 | 13 Sep 2023 |
|---|---|
| Reference | 2023-0330 |
| Deceased | Melissa Kerr |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
declared dead. There is limited documentary evidence as to the procedures performed. Expert evidence was heard that certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat em bolus occurring, namely the choice of access incision for the augmentation cannula and the decision to inject fat into the superficial muscle. 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: 1. Expert evidence was heard that the findings in this case are consistent with findings in other cases where patients have died following autologous fat transfer to the gluteal area during an operation colloquially known as Brazilian Buttock Lift. I understand from the evidence heard that due to the high mortality associated with this procedure a voluntary moratorium on the practice of this procedure has been introduced in the UK. Recommendations for safer practices have emerged that recommend significant changes to practice. 2. I am concerned that patients travelling to Turkey for this procedure are not being made aware of the risks and the high mortality rate associated with this surgery 3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place. Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure. There was limited psychological and physical assessment prior to the procedure proceeding. 4. I appreciate the UK Government has no control over what happens abroad. However I am concerned that citizens are travelling abroad for such procedures unaware of the risks involved and that practices are used which are regarded as unsafe in the UK. 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 November 07, 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 - Mother. I have also sent it to Private Medicana Haznedar Hospital The British Association of Aesthetics and Plastic Surgeons - Expert 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. 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 15 November 2023 Mrs Jacqueline Lake HM Senior Coroner County Hall Martineau Lane Norwich NR1 2DH Dear Mrs. Lake, Thank you for your letter issued on 13 September 2023 to the Secretary of State for Health and Social Care about the death of Melissa Hannah Kerr. 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 Melissa’s death. I can 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. 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 the number of UK nationals travelling to the country for medical treatments. 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 Kerr in Türkiye. 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. It is particularly important that those considering having the ‘Brazilian Butt Lift’ (BBL) procedure are made fully aware of the risks and have time to reflect fully on their decision ahead of surgery. As you note in the report, the risks associated with this procedure are high. The risk of death for BBL surgery is at least 10 times higher than many other cosmetic procedures, and it has the highest death rate of all cosmetic procedures. As you note, the British Association of Aesthetic Plastic Surgeons (BAAPS) has advised its members not to carry out Brazilian butt lift surgery until more is known about safer techniques for the procedure. 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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