Tracy Gambrill
24 Oct 2023 · Coroner Susan Evans · South Yorkshire (Western)
The coroner's concerns
1. excessive depth of surgical incisions
“Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn”
2. lack of routine intra-operative incision measurement
“The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times”
3. absence of standardised incision measurement practice
“I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation”