Mrs Lily Townsend · Prevention of Future Deaths report

On the 25 April 2017, I commenced an investigation into the death of the late Mrs Lily Townsend. The investigation concluded at the end of the inquest on 12 June 2017. The conclusion of the inquest was a short narrative conclusion of:

“Died after developing a rare but recognised complication of pulmonary fat embolism due to bone cement implantation syndrome”.

The cause of death was:

1a Pulmonary Fat Embolism
1b Bone Cement Implantation Syndrome
c
II Ischaemic Heart Disease and Pulmonary Fibrosis

i) Mrs Townsend had an unwitnessed fall at home in her bathroom on the evening of 11 February 2017 and was admitted to Sandwell Hospital on the 12 February.

ii) She had a medical history including cancer, severe cardio pulmonary disease, atrial fibrillation and pulmonary fibrosis. A fractured neck of femur was diagnosed.

iii) Inadequate medical history was taken during the preoperative assessment and a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.

iv) On the 13 February, she underwent cemented hemiarthroplasty and when the cement was applied her oxygen saturation and blood pressure dropped rapidly and despite attempts at resuscitation she was pronounced deceased at 1pm.

1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.

2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.

3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.

4. The Trust initiated an internal investigation and identified that the root causes were:

a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.

b) Consent process inadequate.