Source · Prevention of Future Deaths
Monique Whitbread
Ref: 2014-0368
Date: 30 Jul 2014
Coroner: ME Hassell
Area: London North (Inner)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified that performing a gastric bypass on a patient with a hernia risked strangulation, leading to death. The report noted a need to disseminate nationally the surgeon's learning that a sleeve gastrectomy is a safer alternative for such patients.
Date
30 Jul 2014
56-day deadline
24 Sep 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner identified that performing a gastric bypass on a patient with a hernia risked strangulation, leading to death. The report noted a need to disseminate nationally the surgeon's learning that a sleeve gastrectomy is a safer alternative for such patients.
View full coroner's concerns
Ms Whitbread had a body mass index of above 50 and was referred for bariatric surgery. She also had a hernia. Her surgical options were:
- gastric band
- sleeve gastrectomy
- gastric bypass.
You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate, and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia. Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation.
It seems from your evidence that it would be helpful to disseminate your experience and observations nationally.
- gastric band
- sleeve gastrectomy
- gastric bypass.
You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate, and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia. Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation.
It seems from your evidence that it would be helpful to disseminate your experience and observations nationally.
Report sections
Investigation and inquest
On 1 April 2014, I commenced an investigation into the death of Monique Whitbread, aged 49 years. The investigation concluded at the end of the inquest on 23 July. The determination I made at inquest was that Monique Whitbread died from a recognised complication of medical treatment.
Circumstances of the death
Ms Whitbread’s medical cause of death was:
1a pulmonary aspergillosis and sepsis; 1b intra abdominal complications related to bariatric procedures; 1c laparoscopic gastric bypass on 09.01.14 for obesity; 2 diabetes mellitus, hypertension.
1a pulmonary aspergillosis and sepsis; 1b intra abdominal complications related to bariatric procedures; 1c laparoscopic gastric bypass on 09.01.14 for obesity; 2 diabetes mellitus, hypertension.
Copies sent to
Professor Dame Sally Davies, Chief Medical Officer for England
Similar PFD reports
Report details
- Reference
- 2014-0368
- Date of report
- 30 July 2014
- Coroner
- ME Hassell
- Coroner area
- London North (Inner)
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: 24 Sep 2014 (estimated from the report date).
Sent to
- University College Hospital