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recurance

Beryl Dandridge

12 Jun 2024 · Coroner Nicholas Graham · Oxfordshire

The coroner's concerns

  1. 1. inappropriate echocardiogram requirement for vulnerable patients

    “conflicting views between clinicians regarding the need for an echocardiogram for vulnerable patients pending periprosthetic surgery and the circumstances when surgery might be appropriately delayed pending such a scan”
  2. 2. lack of responsibility for expediting echocardiogram

    “unclear which clinicians was responsible for expediting such a scan in circumstances where the evidence indicated that delays in surgery is associated with poorer outcomes for vulnerable patients”
  3. 3. inadequate Structured Mortality Review input

    “Structured Mortality Review was critical of the decision to require an echocardiogram pending surgery”

Responses

2026-0272-Response-from-Oxfordshire-County-Council.pdf ↗· Oxford University Hospitals NHS Foundation Trust

Stated action

“We convened a group of experts at the Learning Multi-disciplinary Team meeting including the Orthogeriatrician team and the Anaesthetist involved in this case and have agreed that whilst the same principles of the AAGBI guidelines apply to patients with periprosthetic fractures as to other femoral fragility fractures, these cases present a more complex risk / benefit analysis due to the increased length of operation and complexity of the surgery and therefore each patient will require an individ”

Stated action

“This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant [name redacted] team and the escalation will go through the on”

Stated action

“The OUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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