Freda Lennox
10 May 2022 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. lack of echocardiogram prior to surgery
“Mrs [name redacted] had previous pre-operative assessments in 2018 and 2019 and a respiratory review in February 2020. Following a telephone consultation in September 2020 an echocardiogram was requested to look for pulmonary hypertension and/or the development of Cor Pulmonale but this had not been carried out prior to her surgery.”
2. lack of recent orthopaedic review
“Mrs [name redacted] had not been recently reviewed by the consultant orthopaedic surgeon prior to her admission on 2nd November 2020 despite her medical co-morbidities having given rise to concerns as to her suitability for an elective total hip replacement.”
3. anaesthetist not informed of patient comorbidities
“The consultant anaesthetist was not informed about Mrs [name redacted] and her medical co-morbidities prior to her admission. Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs [name redacted] consented for surgery.”
4. lack of funding for high-risk anaesthetic clinic
“Evidence was heard that there was a lack of funding for a dedicated high-risk consultant led anaesthetic pre-operative assessment clinic with the necessary equipment to be able to suitably risk assess patients prior to any potential surgery.”
5. lack of dedicated room and secretarial support
“There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service.”