“Notwithstanding (a) the death of Ms Cambridge on 27.8.18; and (b) concerns expressed in…”
Dated 29 Nov 2019, from the coroner for West Yorkshire (Eastern). Sent to 2 organisations or people.
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 24 Jan 2020.
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 dated29 Nov 2019
- Deadline24 Jan 2020
- Published on judiciary.uk29 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| General Medical CouncilNamed in the report as “GMC” | Response publishedPublished on judiciary.uk in December 2019. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in December 2019. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) Notwithstanding (a) the death of Ms Cambridge on 27.8.18; and (b) concerns expressed in relation to the risks involved in BBL procedures by a task force established under the auspices of the Aesthetic Surgery Education and Research Foundation (ASERF); and (c) a voluntary moratorium declared by the British Association of Aesthetic and Plastic Surgeons (‘BAAPS’) The Inquest heard evidence that some plastic surgeons in the UK continue to carry out BBL procedures. Furthermore, that Elite Aftercare continue to facilitate other clients to travel to Turkey for the purpose of BBL procedures to be undertaken by surgeons such as . I am concerned at the lack of intervention and control of BBL procedures by the regulatory authorities in the UK. (2) In order to make an informed decision as to the wisdom of undertaking effective cosmetic surgical procedures such as BBL, it is important that the person involved receive adequate information regarding the mortality and morbidity risks involved. In order to read and absorb such information it needs to be provided prior to any commitment being made or expense incurred. The Inquest into the death of Ms Cambridge heard that she was provided with a substantial quantity of material (some of which was written in Turkish) on the morning of the surgery and required to sign each page. The Inquest found she had insufficient time to digest this complex material, even if she was in a frame of mind to try, shortly before being taken to theatre. My concern is that informed consent is not obtained. (3) If BBL procedures continue to be permitted in the UK, I consider there is a need for the regulatory authorities to consider providing guidance on the surgical techniques to be employed and the information to be provided before a person incurs expense.
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, 2019-0408
- Added to Minute Book
- 8 Oct 2026
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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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