“Each of the three surgical incisions were far too deep considering the average distance…”
Dated 24 Oct 2023, from the coroner for South Yorkshire West. Sent to 4 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
Deadline passedReplies were due by 19 Dec 2023. A reply may have been sent and not yet published.
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.
- Report dated24 Oct 2023
- Deadline19 Dec 2023
- Published on judiciary.uk1 Nov 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Royal College of Surgeons of England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Dec 2023. A reply may have been sent and not yet published. |
| General Medical CouncilNamed in the report as “The General Medical Council” | Response publishedPublished on judiciary.uk in November 2023. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Dec 2023. A reply may have been sent and not yet published. |
| The Society of British Neurological Surgeons | Response publishedPublished on judiciary.uk in November 2023. |
The coroner’s concerns
– Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position. I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
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, 2023-0405
- 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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