Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0116, written 10 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2025 |
|---|---|
| Reference | 2025-0116 |
| Deceased | Anne Towlson |
| Coroner | Isobel Thistlethwaite |
| Coroner area | Rutland and North Leicestershire |
| 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: The Secretary of State for Health and Social Care 1 CORONER I am Miss I THISTLETHWAITE, His Majesty's Assistant Coroner for the coroner area of Rutland and North Leicestershire. 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 31 May 2024 I commenced an investigation into the death of Anne TOWLSON aged 58. The investigation concluded at the end of the inquest on 10 February 2025. The conclusion of the inquest was that: The cause of Mrs Towlson’s death was unascertained at post-mortem, however, on the balance of probabilities her death was caused or contributed to by the cosmetic surgery that she underwent in Instanbul, Turkey, in the weeks before death. The cause of death was established as: I a Unascertained I b I c II 4 CIRCUMSTANCES OF THE DEATH Mrs Towlson was a 58 year old female who was found dead at her home address on 17 May 2024. Mrs Towlson travelled to Turkey on 24 April 2024 where she underwent a pre-planned tummy tuck and liposuction. On arrival at the hospital she was told she could have an arm tuck surgery as well and she opted to undergo that at the same time, this was said to be a “last minute decision”. Mrs Towlson’s arm wounds did not heal like the wound to her tummy did when she was found dead it was noted that she had open wounds to her armpits and triceps and her right arm was “swollen and weeping”. Regulation 28 – After Inquest Document Template Updated 16/05/2023 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: Pre-amble The inquest heard evidence that Mrs Towlson travelled by plane to Turkey on 24 April 2024 to have a tummy tuck and liposuction. She went straight to the Green Park Hospital in Pendic, Istanbul on 24 April 2024. Mrs Towlson was informed on arrival that it was also possible to have arm tuck surgery at the same time as her planned tummy tuck and liposuction and she made a “last minute decision” to have arm tuck surgery as well. Immediately post-surgery Mrs Towlson complained that her right arm was hurting and her compression garments were too tight, her right hand was said to have swelled up like a balloon and was seeping a clear liquid. She remained in hospital for three days before returning to a hotel on 27 April 2024. Mrs Towlson returned to the hotel with a total of eight drains coming out of her body, she was leaking a yellow and slightly odorous fluid from her arms which would stain the hotel pillows. Mrs Towlson was using What’s App to communicate with the hospital whilst she was at the hotel. Mrs Towlson returned to the hospital twice, once on 2 May 2024 because one of her drains had come out and the final time on 3 May 2024 to have the remaining drains removed. Mrs Towlson was given anti-biotics, anti-inflammatories, painkillers and a cream to take with her. She flew home to Manchester Airport on the same day, 3 May 2024. From 4 May 2024 to the time she died Mrs Towlson’s internet search history shows that she was searching for things like “infected stitches symptoms”, “wound dehiscence” and “armpit yeast infection symptoms”. On 7 May 2024 Mrs Towlson sent a video of her arm and armpit with a sticky yellow and white pus present at the site of the top of the arm tuck scarring to the hospital. They responded saying that they would show the video to a Doctor, that was the last What’s App communication received from the hospital. On 11 May 2024 Mrs Towlson was seen by her neighbour and was communicating with her daughter, she told her daughter that her tummy was ok but her arm was “killing her”. Mrs Towlson made her last outgoing call on this date at 12:27hrs. On 17 May 2024 Mrs Towlson was found dead and decomposing at home. Police attended the scene and took photographs which clearly show the tummy tuck wound healing nicely but show open wounds to Mrs Towlson’s armpits and triceps, her right arm was said to be “weeping and swollen”. The surgery to both arms remained unhealed. A post mortem concluded that the cause of Mrs Towlson’s death was 1a) Unascertained. Concerns Regulation 28 – After Inquest Document Template Updated 16/05/2023 1) I am concerned about the fact that the inquest was unable to secure any information from the Turkish Hospital. We have no information about whether any independent enquiries were made either by the company who organised Mrs Towlson’s trip to Turkey for surgery, or the Turkish Hospital itself as to whether Mrs Towlson was fit for surgery. We have not been able to secure her medical records so have no understanding of what exactly the surgery consisted of, or what post- operative care and treatment was provided to Mrs Towlson. 2) I am concerned about the fact that we have no evidence to confirm whether Mrs Towlson was made aware of the risks and mortality rates associated with any of the surgical procedures she underwent in Turkey. 3) I am concerned about the fact that Mrs Towlson had travelled to Turkey to have a tummy tuck and liposuction but was offered additional arm tuck surgery when she arrived at the hospital. I have concerns about the consenting process for this additional surgery as, on the balance of probabilities, Mrs Towlson was not given enough time to properly consider this decision. 4) Whilst I appreciate the UK Government has no control over what happens abroad, I am concerned about the fact that British Citizens are travelling abroad for significant and serious surgical operations with seemingly little in the way of follow up and no way to return easily to the operating Hospital if they encounter complications once they are back in the UK. This is not only dangerous but could place a significant burden on the NHS. 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 April 7, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mrs Towlson’s family I have also sent it to Green Park Hospital in Pendic, Istanbul The British Association of Aesthetics and Plastic Surgeons 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 Regulation 28 – After Inquest Document Template Updated 16/05/2023 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 Dated: 10/02/2025 Miss I THISTLETHWAITE His Majesty's Assistant Coroner for Rutland and North Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
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 Parliamentary Under-Secretary of State for Public Health and Prevention 39 Victoria Street London SW1H 0EU Miss Isobel Thistlethwaite Assistant Coroner for Rutland and North Leicestershire HM Coroner's Office Leicestershire County Council County Hall Glenfield Leicestershire LE3 8RA By email: Dear Miss Thistlethwaite, 7 April 2025 Thank you for the Regulation 28 report of 10th February 2025 sent to the Secretary of State for Health and Social Care about the death of Anne Towlson. I am replying as the Parliamentary Under-Secretary of State with responsibility for Public Health and Prevention. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Towlson’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning, and I am grateful to you for bringing these matters to my attention. The report highlights concerns over the inability to secure any medical record information from the Turkish Hospital or from the company that organised Mrs Towlson’s trip to Turkey, the upselling of certain procedures in Turkey without the normal cooling-off period, and whether Mrs Towlson was fit for surgery. It also raises troubling details about the lack of post-operative guidance and after-care provided before she left the country. Specifically, I have noted in your report the lack of information on whether the standard pre-assessment questions provided to Ms Towlson in Turkey were satisfactory in determining whether she was fit for surgery. We are aware that some countries or clinics providing healthcare tourism conduct pre-assessment checks that may not match UK regulatory standards, and we encourage providers treating UK nationals to meet international best practice on pre- and post-operative procedures. Such transparency and standardisation are important to reduce potential risks to patients and improve patient care in the UK and overseas. We are considering the impact medical tourism is having regarding patient safety and are engaging with the Turkish Government to improve the patient pathway. The UK Government is also considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks of surgery and help them to plan accordingly. To protect patient safety, we understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home. In preparing this response, my officials have also notified NHS England and the Care Quality Commission to inform them of the issues raised. I hope this response is helpful in setting out how seriously the UK Government is taking the issues raised in your report. Thank you for bringing these concerns to my attention. Yours sincerely,
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