“(brief summary of matters of concern) Queen Alexandra’s written post operative care…”

The coroner’s concerns

(brief summary of matters of concern) Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that: There is to be a daily review by a bariatric specialist nurse, consultant or registrar. A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed. In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy. Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all. The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain. The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.

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, 2024-0687

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