Reginald Smith: Prevention of Future Deaths Report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 21/01/2025 

Ref: 2025-0037 

Deceased name: Reginald Smith 

Coroners name: Richard Middleton 

Coroners Area: Dorset 

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

This report is being sent to: The British Orthopaedic Association | Stryker (UK) Ltd

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
 
The British Orthopaedic Association
Managing Director of Stryker (UK) Ltd
1CORONER
 
I am Richard T Middleton, Assistant Coroner, for the Coroner Area of Dorset
2CORONER’S LEGAL POWERS
 
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3INVESTIGATION and INQUEST
 
On the 14th December 2023, an investigation was commenced into the death of Reginal Victor Smith, born on the 11th June 1933.
 
The investigation concluded at the end of the Inquest on the 10th January 2025.  
 
The Medical Cause of Death was:
 
1a   Hypovolemic Shock
 
1b   Re operation of fractured neck of femur
 
1c    Fractured neck of femur
 
II
 
The conclusion of the Inquest recorded that Reginald Victor Smith died as a consequence of a rare but recognised complication of a surgical procedure.
4CIRCUMSTANCES OF THE DEATH
 
On 9/10/23 Mr Smith had a witnessed fall at his care home. He was admitted to Poole Hospital where he underwent surgery to repair a right extra capsular neck of femur fracture on 12/10/23. The surgery involved Mr Smith being laid on a traction table and a jig was used to align the fracture for screws to be inserted into a titanium nail which is placed into the femur.

On 24/10/23  he was discharged from hospital. On 5/12/23 he attended Poole Hospital for a review appointment when X rays disclosed a failure of metalwork inserted on 12/10/23 and he was readmitted to hospital. On 7/12/23 Mr Smith underwent revision surgery. It was apparent that the hip screw was slightly off centre and being approximately 1mm-2mm off centre did not make proper contact with the nail. Following surgery his health deteriorated. Mr Smith received palliative care and he died in hospital on 7/12/23.
5CORONER’S CONCERNS
 
The MATTERS OF CONCERN are as follows: 
 
1) During the inquest evidence was heard that:
 
i) Evidence was given to suggest there were two probable reasons for the hip screw not correctly passing into the nail:
 
firstly, before the femoral nail and jig were inserted it may be that the jig was loose and needed tightening or
        
secondly, the jig used might have been slightly bent
 
2) I have concerns with regard to the following:
 
i) Each jig is used many times in surgery having been sterilised after each procedure. It is hammered into the thigh bone and on this occasion may have become deformed over time.

ii) The jig was sent away to the manufacturer for analysis but was lost and so no information was available to the court in relation to its integrity.

iii) There is no quality control in place in relation to the examination of the jigs being used (other than when it is assembled in theatre by a nurse) prior to surgery. There is no auditing/ spot checks in relation to the integrity of the jigs.
6ACTION SHOULD BE TAKEN
 
In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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, by 18th March 2025.  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 Chief Coroner and to the following Interested Persons:
 
 Mr Smith’s Family
 
I am also under a duty to send the Chief Coroner a copy of your response.
 
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 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 by the Chief Coroner.
9Dated
21st January 2025
Signed
Richard T Middleton