Emma Morrissey
4 Sept 2023 · Coroner Jacqueline Devonish · Cheshire
The coroner's concerns
1. patient self declaration of health without independent verification
“The health tourism company Regenesis UK relied upon patient self declaration of health and made no independent enquiries to satisfy themselves that [the deceased] was fit for the gastric sleeve procedure before making the arrangement for her to have surgery at the Termessos Hospital, Antalya in Turkey.”
2. unclear pre-assessment questions lacking standard form and family history enquiry
“The series of health related pre-assessment questions asked before referral to the private hospital in Turkey were unclear, as there was no evidence of a standard form produced by a medically trained source for the referring staff to refer to. The questions did not include an enquiry about family history of medical conditions such as cardiac related relevant to”
3. lack of investigation into operating table death
“There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation.”
4. inadequate embalming process for repatriation
“The embalming process for repatriation from Turkey to the UK was inadequate due to there being no evidence of fluid perfused to the great vessels, leaving [the deceased]'s body at risk of infection during transit. This presented a risk of decomposition as well as a health risk to the professionals receiving her body in the UK.”
5. discrepancy between surgery note and post-mortem findings
“The surgery note provided to Regenesis stated that the sleeve gastrectomy operation was not completed following the intra-abdominal bleed in the omentum. The UK post mortem confirms that the surgery had been completed and that the site of the bleed was the lieno-renal ligament and not the omentum. The lieno-regal ligament site had been packed to stem the bleed during the operation and was present at post mortem.”
6. misclassification of death as natural when unnatural
“The cause of death reported in Turkey was natural. It was recorded as la, Cardigenic Shock, due to lb. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument.”