Renee Simone Brooks · Prevention of Future Deaths report

On 10/09/2019 I commenced an investigation into the death of Renee Simone Brooks. The investigation concluded at the end of an inquest on 14th January 2020. The Conclusion of the inquest was that she died from a recognised but rare complication (fat embolism syndrome) of a necessary procedure, contributed to by pre-existing cardiac issues.

Mrs Brooks had debilitating lipoedema from the waist down and in her upper limbs, causing significant mobility impairment and pain. Her BMI was 46.1. She underwent rehabilitation and functional liposuction procedures in June, July and August 2018 and January 2019. These procedures were uneventful, she recovered well, and benefited from an improvement in her quality of life. On 29 August 2019 she underwent what was intended to be the final procedure on her legs. The risks, including fat embolism syndrome, were considered and consented to. The risk of mortality was considered low. The procedure took about 4 hours and was performed as planned. At the end of the procedure she suddenly went into cardiac arrest and after about 7 minutes was resuscitated and taken to Birmingham Heartlands Hospital. She remained very poorly and despite maximum treatment died on 30 August 2019. Post-mortem tests revealed she had a pre-existing significantly enlarged heart and fat embolisms were found in her lungs.

Having heard evidence from the pathologist and her treating clinicians, the Coroner determined the medical cause of death to be:
1a MULTIPLE ORGAN FAILURE (PERI-OPERATIVE CARDIAC ARREST)
1b FAT EMBOLISM SYNDROME.
1c LIPOEDEMA (LARGE VOLUME LIPOSUCTION PROCEDURE)
2. COR PULMONALE. OBESITY CARDIOMYOPATHY.

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.