31 Jan 2020 Renee Simone Brooks · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of UK guidance on the safe frequency of lipoedema-related liposuction procedures View source Lack of UK guidance on the amount of fluid to remove during lipoedema-related liposuction View source Lack of UK guidance on the amount of fluid to put into patients during lipoedema-related liposuction View source Lack of UK guidance on post-procedure patient recovery plans for lipoedema-related liposuction View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Renee Simone Brooks · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Renee Simone Brooks underwent a final large-volume liposuction procedure on 29 August 2019, suffered cardiac arrest during the procedure, and died in hospital on 30 August 2019. The inquest identified fat embolism syndrome as a recognised but rare complication, with pre-existing cardiac issues contributing. The principal concern was the absence of UK guidance on safe practice for lipoedema-related liposuction, including procedure frequency, fluid volumes, and post-procedure recovery planning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Aesthetic Plastic Surgeons; that does not assign responsibility.
PFD Monitor interpretation Lack of UK guidance on the safe frequency of lipoedema-related liposuction procedures
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient , (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Aesthetic Plastic Surgeons; that does not assign responsibility.
PFD Monitor interpretation Lack of UK guidance on the amount of fluid to remove during lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure , and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Aesthetic Plastic Surgeons; that does not assign responsibility.
PFD Monitor interpretation Lack of UK guidance on the amount of fluid to put into patients during lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure , (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Aesthetic Plastic Surgeons; that does not assign responsibility.
PFD Monitor interpretation Lack of UK guidance on post-procedure patient recovery plans for lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan . Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit the completed liposuction guidelines to the CQC for use when inspecting premises involved in liposuction.
Verbatim wording from the response “The majority of liposuction in the UK is likely to be carried out by such practitioners and so we intend to submit these guidelines to the CQC for their use in the inspection of premises involved in liposuction.” Source location 2020-0260-Response-from-BAAPS-and-BAPRAS_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forward the guidelines to the coroner for inspection before publication.
Verbatim wording from the response “We will forward the guidelines for your inspection prior to publication.” Source location 2020-0260-Response-from-BAAPS-and-BAPRAS_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop combined UK guidelines for the safe use of liposuction, covering lipoedema, cosmetic procedures, hospital support, pre-assessment and multidisciplinary review.
Verbatim wording from the response “We write in response to your Regulation 28 Report to prevent further deaths in relation to liposuction and the treatment of lipoedema. As a result of this request, both associations (BAPRAS & BAAPS) have agreed to work in partnership to create guidelines for the use of liposuction in the UK.” Source location 2020-0260-Response-from-BAAPS-and-BAPRAS_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint BAAPS and BAPRAS expert panel with relevant surgical, anaesthetic and stakeholder representation.
Verbatim wording from the response “In order to create the guidelines, we have set up a joint BAAPS & BAPRAS expert panel. This panel will include invited expert members of both surgical associations, a member of the Association of Anaesthetists and any other relevant stakeholders that the co-chairs believe to be appropriate. Their report is intended to cover not only the specifics of the procedure but also the level of hospital support required, any pre-assessment needs and the potential need for a multi-disciplinary team (MDT) meeting for lipoedema patients. It is hoped that we can produce this report within the next six months and that it will be adopted by the wider sector, including those practitioners who are not members of our associations.” Source location 2020-0260-Response-from-BAAPS-and-BAPRAS_Redacted.pdf
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations