Judith VARLEY · Prevention of Future Deaths report

Date investigation opened 11th December 2019.
Date inquest concluded 21st April 2021.

Conclusion Narrative –On 2nd December 2019 Judith Varley underwent right hip replacement surgery at The Yorkshire Clinic Bingley West Yorkshire.

During the course of the operation she suffered sudden catastrophic bleeding which despite all appropriate medical and surgical efforts resulted in her death during the procedure.

It is likely that the bleeding was from a tear to the femoral vein which occurred when her treating surgeon undertook a necessary manipulation of her hip joint during the operation.

In March 2009 Mrs Varley suffered an accident sustaining extensive burns to the left side of her body, despite hospital treatment she developed complications leading to an above knee left leg amputation.

During this time she was also diagnosed with peripheral vascular disease and underwent a right sided ileo-femoral bypass graft to improve the blood supply to her right leg.

In 2013 she underwent further vascular procedures namely an angioplasty and patch repair at the sight of her previous by-pass graft.

In 2019 she developed right hip pain, she consulted your practice and was referred by letter to Mr Thomas consultant orthopaedic surgeon, who recommended right hip replacement surgery.
During the course of surgery undertaken at The Yorkshire Clinic Bingley on 2nd December 2019, Mrs Varley suffered a catastrophic bleed, which despite both medical and surgical intervention led to her death in the operating theatre a short time later.
During the course of the inquest, it was established that the coding given and entered on the computer system of the Wilsden Practice for Mrs Varley’s surgery in 2013 was not in fact an accurate description of the surgery which she had undergone at that time.

This led to an inaccurate description of this surgery within the referral letter submitted by Wilsden Practice at the time of Mrs Varley referral in 2019 for her right hip pain.
In the inquest evidence ████████ from the practice.

1. she was unable to clarify if there was in fact an alternative coding in 2013 which would have accurately reflected the surgery performed.
2. She was not familiar with the system to know if the coding can be overridden so as to ensure an accurate description of a procedure can be recorded, when the coding options available do not provide an accurate description
3. As she is not the designated doctor within the practice, she was not aware of what auditing / reviewing systems operated within the practice so as to ensure the accurate inputting of information into the practices computer system

I would wish to stress that there was no evidence at the inquest which indicated that this issue in any way caused or contributed to Mrs Varley’s death. However I consider that this issue does potentially pose a risk which could impact on the lives of others, hence the reason for reporting this matter to you.

1. The computer coding entered by the practice in respect of Mrs Varley’s 2013 procedures did not accurately describe the procedure undertaken.

2. It was unclear whether the operating coding computer system in 2013 had facility to be overrided to ensure an accurate description was entered on the system.

3. It was unclear if there was /is an auditing / quality control system in place in the practice to ensure accurate inputting of information within the coding process.