Source · Prevention of Future Deaths
Rosalind Baird
Date: 2 Sep 2015
Coroner: David Horsley
Area: Portsmouth and South East Hampshire
0 responses identified · 1 indexed addressee
View PDF
AI-generated concerns summaryThe coroner noted a lack of a formal national monitoring scheme for inexperienced surgeons carrying out procedures. Consideration should be given to developing a national scheme, using the Queen Alexandra Hospital's model as an example of good practice.
Date
2 Sep 2015
56-day deadline
28 Oct 2015
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of a formal national monitoring scheme for inexperienced surgeons carrying out procedures. Consideration should be given to developing a national scheme, using the Queen Alexandra Hospital's model as an example of good practice.
View full coroner's concerns
At the time of Mrs Baird's nephrectomy there was no formal scheme for the monitoring of inexperienced surgeons carrying out surgical procedures. Since that time, Queen Alexandra Hospital has adopted a formal scheme (see attached): was told that such schemes are not widespread in England and no such scheme has been formulated at national level: To help prevent deaths in circumstances similar to those of Mrs Baird, consideration should be given to a national monitoring scheme for inexperienced consultant surgeons being compiled using the Queen Alexandra Hospital scheme as an example of good practice.
Report sections
Investigation and inquest
On 12 November 2014 commenced an investigation into the death of Rosalind Jane Anne Bernadette Baird. investigation concluded at the end of the inquest on 30 June 2015. The conclusion of the inquest was: Medical cause of death: 1a: Bronchopneumonia 1b: Small Bowel Ischaemia requiring Small Bowel Resection 1c: Superior Mesenteric Artery Injury during Nephrectomy for Kidney Tumour Coroner's Conclusion: Death due to an Accident On 20 October 2014 Rosalind Baird underwent a left nephrectomy at Queen Alexandra Hospital, Portsmouth, during the course of which a blood vessel supplying her bowel was cut. Thereafter her condition deteriorated and despite further surgery and other medical treatment; she died at the hospital at approximately 22.00 hours on 05 November 2014.
Circumstances of the death
See above
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Similar PFD reports
Report details
- Date of report
- 2 September 2015
- Coroner
- David Horsley
- Coroner area
- Portsmouth and South East Hampshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Oct 2015 (stated in the report).
Sent to
- Dept. of Health