In a recent inquest Darragh Coffey, instructed by Nandi Jordan of Leigh Day, represented the family of a 39-year-old mother of four, who died following elective hip surgery in March 2023.
Following a three-day inquest, HM Senior Coroner for North Inner London identified multiple failures at the Royal London Hospital that led to the previously fit and healthy woman’s death, following complications that arose during a planned periacetabular osteotomy. This surgery was intended to correct the patient’s congenital hip dysplasia. However, the Coroner found that, due to inexperience, and lack of supervision, mentoring and appropriate support structures, the operating consultant orthopaedic surgeon should not have been permitted to offer this complex surgery at the Royal London Hospital.
The Coroner went on to find that when the surgeon encountered significant bleeding from a vein during the procedure, he failed to follow the accepted procedure and keep the wound packed, and await blood transfusion and vascular surgical support. It was also identified that that there a deterioration in communication and a lack of adaptability and assertiveness in the operating theatre. This resulted in a delay in the anaesthetist asking for crossmatched blood products and a further delay in the arrival of the blood products once they were requested due to a failure to follow procedures. The Coroner also identified a lack of clarity regarding the system in place for calling a vascular surgeon.
In a narrative conclusion, HM Coroner stated that:
“If the wound had been packed effectively; blood and blood products had been given promptly and certainly by 3.30pm; and the team had then monitored pending the arrival of a consultant vascular surgeon, [the patient] would not have died.”
The Coroner stated her intention to make a Prevention of Future Deaths Report following the conclusion of the Inquest.
