“Evidence emerged during the inquest that during the preoperative assessment inadequate…”
Dated 15 Jun 2017, from the coroner for Black Country. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 10 Aug 2017.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated15 Jun 2017
- Deadline10 Aug 2017
- Published on judiciary.uk9 Aug 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sandwell and West Birmingham Hospitals NHS Trust | Response publishedPublished on judiciary.uk in August 2017. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension. 2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given. 3. The risks of the procedure may have been reduced by performing an uncemented operation given the known potential cardiopulmonary complications of cement. 4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk. b) Consent process inadequate.
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, 2017-0191
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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