Chamali Bibi: Prevention of Future Deaths Report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 09/10/2024 

Ref: 2024-0540 

Deceased name: Chamali Bibi 

Coroners name: Mary Hassell 

Coroners Area: Inner North London 

Category: Hospital Death (Clinical Procedures and medical management) related deaths 

This report is being sent to: NHS England 

Regulation 28: Prevention of Future Deaths Report
THIS REPORT IS BEING SENT TO:

1. [REDACTED]
National Medical Director
NHS England 
Wellington House 
133-135 Waterloo Road 
London SE1 8UG 
1CORONER

I am: Coroner ME Hassell 
Senior Coroner  
Inner North London 
St Pancras Coroner’s Court
Camley Street 
London  N1C 4PP 
2CORONER’S LEGAL POWERS

I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 
3INVESTIGATION and INQUEST

On  7  March 2023 I commenced an  investigation into the death of Chamali Bibi, aged 39 years.  
The inquest was listed for 15 August 2023, but the investigation was not concluded until the end of the inquest on 25 September 2024.   
I made a narrative determination at inquest, which I now attach.
4CIRCUMSTANCES OF THE DEATH

Ms Bibi underwent a right periacetabular osteotomy (PAO) on 01.03.23, during which she suffered haemorrhagic shock that led to a stroke that evening. 
5CORONER’S CONCERNS

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.

As you will see from the narrative determination attached, there were several  matters  requiring  attention  at  the  Royal  London  Hospital. However, I do not intend to make a prevention of future deaths (PFD) report to Barts Health, because I was given undertakings in court that these matters have already been addressed. 
The issue that I bring to your attention is this.   At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with  mentor  feedback  on  the  surgery  taking  into  account  the  post operative imaging, can gain the necessary experience to become expert.
However, the majority of the surgeons on the specialist register are the only  practitioners  within  their  trust  performing  the  surgery  and  the majority undertake fewer than ten per annum each. Further, the register is voluntary.  Outliers do not appear to have been flagged. 
It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique. 
6ACTION SHOULD BE TAKEN

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.  
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 December 2024.  I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 
8COPIES and PUBLICATION

I have sent a copy of my report to the following.
 
[REDACTED], husband of Chamali Bibi
[REDACTED], Chief Medical Officer for England
HHJ Alexia Durran, the Chief Coroner of England & Wales 

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it useful or of interest.  
The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she  believes  may  find  it  useful  or  of  interest.  You  may  make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 
9DATE
09.10.24
SIGNED BY SENIOR CORONER
ME Hassell