Rosina Drury · Prevention of Future Deaths report

On 11th May 2015, I opened an inquest into the death of:
Rosina Drury, who died on 21st October 2013 in Kings College Hospital, Case Ref: ████████

Her medical cause of death was: 1a fat embolism 1b Bone cement implantation II Fractured right femur (operated). It was concluded that she died of unintended consequences of necessary medical treatment.

Evidence was heard that:

The deceased had ischaemic heart disease (a myocardial infarct in 2009), atrial fibrillation (on Warfarin), hypertension, recently recovered chest infection and diabetes, but she was fit and although unsteady, independent. She fell, fracturing her hip. A right hemiarthroplasty was chosen and she died of a rare complication. Evidence was heard from the consultant orthopaedic surgeon that uncemented arthroplasties, that avoid fatalities from bone cement implantation, although an embolus is still possible), achieve less good pain control, result in slower mobilization and have a higher mortality at 30 days. The surgeon said that he did not choose the uncemented technique unless the patient was immobile. This remained the position even if there was a history of pulmonary embolus.

The expert opinion read, from ████████ identified that good practice in prevention was pre-operative review within four hours of admission by an orthogeriatrician, to assess and manage multiple co-morbidities. This did not happen in this case and only occurs if the surgeon considers a referral was needed. It was also heard from scientific literature that bone cement implantation should be avoided in high risk cases. She was reviewed prior to surgery by a consultant anaesthetist with appropriate seniority, another of ████████ recommendations.

Does not having a pre-operative orthogeriatric review, recommended by an expert, risk that patients with high risk co-morbidities sometimes have a cemented hemiarthroplasty, when an uncemented one would avoid mortality from bone cement implantation, for which there is no cure or treatment and can be fatal?

It is suggested that KCH NHS Foundation Trust may wish to review arrangements for pre-operative review of patients with sub-capital fractured neck of femur requiring fixation with a hemiarthroplasty.