“Mary Hanson had been seen in combined pituitary clinic by consultant neurosurgeon, and i…”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

— (1) Mary Hanson had been seen in combined pituitary clinic by consultant neurosurgeon, and i consultant endocrinologist on 2 June 2014. Although ME evidence was that the risks of surgery would have been clearly explained to both Mary Hanson and her daughter at that consultation, and that he would have stressed that the risk of serious harm and death is very small, iE evidence was that they had not been advised of a risk of death by any clinician, and that her knowledge as to the risk of death was because of her own research carried out on the internet; (2) There is no record in the medical records of that clinic appointment regarding what risks and benefits were discussed; (3) There are no patient information leaflets for patients considering pituitary surgery to take home and digest, something EEE considered should be provided; (4) The clinic letter sent to Mary Hanson's GP following the clinic does not detai! the tisks and benefits of surgery; (5) The ‘capacity assessment proforma’ does not have a box to fill in the date, nor a box for the clinician's signature, or the signature of others consulted during the capacity assessment process; (6) The ‘best interests proforma’ does not have a box to fill in the date, nor a box for the clinician’s signature, or the signature of other consulted during the capacity assessment process; (7) The best interests proforma’ contains five boxes on the final page: “consideration of the person's beliefs and values that would have been likely to influence [their] decision if [they] had capacity; relevant circumstances [they] would take into account if they were making the decision themselves; the identified risks of the proposed treatment and any alternative treatments; the identified benefits of the proposed treatment and any alternative available treatments; the outcome of the best interest assessment, which should demonstrate the weighing of information, reasons for discounting a particular point of view or the manner in which weight has been applied to certain views. It should demonstrate your analysis and findings as the named decision maker." These questions are clearly central to the best interests assessment, yet they had not been completed by the Staff Nurse carrying out the assessment and were all left entirely blank; (8) Given that GMC guidance on consent is that if a discussion regarding treatment is to be delegated, the person to whom that task is delegated must be suitably trained and qualified, have sufficient knowledge of the proposed treatment and understand the risks involved, it is doubtful whether a staff nurse is likely to be the appropriate person to complete the proforma and take such a decision; (9) When po undertook the consent process on the day of surgery using Consent Form 4, he did not notice that the key boxes on the best interests proforma had not been completed; (10)Consent Form 4 does not contain a section for the clinician to carry out the best interests assessment, and in particular does not have anywhere to list the risks and benefits of treatment, or the balancing of the two, something which both and (EE thought it should.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2015-0148

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0