Emma Louise MORRISSEY · Prevention of Future Deaths report

On 28 July 2022 I commenced an investigation into the death of Emma Louise MORRISSEY aged 44. The investigation concluded at the end of the inquest on 31 August 2023. The conclusion of the inquest was that:

Narrative Conclusion - Died as a result of a massive uncontrolled bleed caused by an instrument perforation within the abdomen during surgery.

On 06 July 2022 Emma Louise Morrissey flew to Turkey's private Termessos Hospital in Antalya for gastric sleeve surgery. Arrangements were made through a health tourism company Regenesis. On 07 July 2022 Emma was operated. The surgeon perforated her abdomen with an instrument. The area was packed to stem the bleed but no platelets for blood clotting were administered causing continued bleeding and her sad death on 08 July 2022 at 12:45 hours.

1. The health tourism company Regenesis UK relied upon patient self declaration of health and made no independent enquiries to satisfy themselves that Emma was fit for the gastric sleeve procedure before making the arrangement for her to have surgery at the Termessos Hospital, Antalya in Turkey.
2. The series of health related pre-assessment questions asked before referral to the private hospital in Turkey were unclear, as there was no evidence of a standard form produced by a medically trained source for the referring staff to refer to. The questions did not include an enquiry about family history of medical conditions such as cardiac related relevant to Emma.
3. There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation.
4. The embalming process for repatriation from Turkey to the UK was inadequate due to there being no evidence of fluid perfused to the great vessels, leaving Emma's body at risk of infection during transit. This presented a risk of decomposition as well as a health risk to the professionals receiving her body in the UK.
5. The surgery note provided to Regenesis stated that the sleeve gastrectomy operation was not completed following the intra-abdominal bleed in the omentum. The UK post mortem confirms that the surgery had been completed and that the site of the bleed was the lieno-renal ligament and not the omentum. The lieno-renal ligament site had been packed to stem the bleed during the operation and was present at post mortem.
5. The cause of death reported in Turkey was natural. It was recorded as 1a, Cardiogenic Shock, due to 1b. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument.