Reginald Victor Smith · Prevention of Future Deaths report

On the 14th December 2023, an investigation was commenced into the death of Reginald 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.

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.

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.