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Woman died after weight operation
Coroner orders ‘review’ of hospital’s procedures after ‘accidental’ death of 23-stone woman
UNIVERSITY College London Hospital has been ordered to review its procedures after a 23-stone woman died following an operation aimed at solving her weight problem.
An inquest heard how mother of three Tracey-Ann Korkmaz underwent a gastric bypass earlier this year in an effort to tackle her obesity.
But the 41-year-old died a week after the operation from blood poisoning, shock and multi-organ failure after her stomach lining was perforated.
The case of Ms Korkmaz, from Fulham, was one of three inquests heard on Tuesday that led coroner Dr Andrew Reid to use his strongest powers to make recommendations to Camden Primary Care Trust, The National Patient Agency and the National Clinical Assessment Agency.
St Pancras Coroner’s Court was also told how Jack Brown, 76, from Enfield and Karen Blakey, 44, who lived in De Beauvoir Town, Islington, died after suffering fatal injuries to their internal organs during non-emergency operations this year.
Dr Reid ruled that all three had died as a result of “accidental adverse healthcare events”.
Ms Blakey, who worked for a modelling agency, died in June, months after complications arose during an operation to remove a pancreatic tumour.
Her pancreas was damaged and her small and lower intestines were removed.
Mr Brown lost two litres of blood during a procedure to remove a tumour from his throat. His spleen had to be removed to avoid his heart flooding with blood. A pathologist ruled his coronary vein was fatally torn by a needle inserted to prevent his heart from flooding.
Mr Brown died on the operating table on May 9.
Although Dr Reid was shown UCLH’s own internal review of the cases, he ordered further inquiries.
“I understand that such a report may well be distressing to those involved in their care and obviously to the families of the patients concerned,” said Dr Reid.
“However, I have concluded that the prevention of similar fatalities of others will be assisted by getting a report to the appropriate authorities so that further examinary reviews of the surgical incident or incidents concerned in these cases can occur.”
In all three cases, surgeons had to carry out unplanned removals of organs after complications arose during surgery.
Dr Reid added: “Those who perform services at the UCH and those who look at adverse incidents and fatality issues need to look at these causes and conduct examinary reviews to supplement others already going on at the trust.”
The UCLH Trust is one of the best performing in the country in terms of its mortality rates.
A UCLH spokesman yesterday: “Surgery is a potentially dangerous activity and UCLH carries out a high percentage of complicated cases due to the specialist nature of its services.
“The trust has every confidence in its audit and review processes that ensure that the risks of surgery are kept to a minimum.”
The trust, he said, conducts internal audits on physicians and surgeons every month.
The spokesman added: “The three cases recently heard by the coroner will be considered by the trust’s quality and safety committee and kept under continuous review to ensure the highest standards are maintained.” |
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