LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report

On 5 September 2018 an investigation was commenced into the death of LEAH LOUISE CAMBRIDGE aged 29. The investigation concluded at the end of the Inquest on 22 November 2019. The conclusion of the Inquest was a narrative. The medical cause of death was:
1a Adipose tissue (fat) embolism.
1b Cosmetic surgical procedure.

Leah L Cambridge aged 29 travelled to Izmir Turkey to undergo a cosmetic surgical procedure under general anaesthetic, known as a Brazilian Butt Lift (‘BBL’).

The surgery commenced on Monday 27 August 2018 some 90 minutes after she was admitted to the hospital at 08:17 hours. The BBL entailed harvesting fat from her stomach using liposuction and then reinserting the fat, (once purified) into her buttocks and thighs using a cannula. A complication arose during the procedure resulting in her being pronounced dead at approximately 13:00 hours the same day. A post mortem examination carried out in England revealed some fat had entered veins in her body leading to a fat embolism, which then caused her death.

Evidence provided at the Inquest from an expert plastic surgeon indicated BBL procedures involve risks considerably greater than any other cosmetic procedure. In consequence, a reputable professional association of plastic surgeons in the UK has declared a voluntary moratorium on BBLs.

The Inquest found that she was asked to sign her name some three dozen times on pages of documents written in Turkish and English without being afforded time to read and digest the contents. As the risks had not been adequately explained to her she undertook the BBL procedure without appreciating the risks involved.

(1) Notwithstanding

(a) the death of Ms Cambridge on 27.8.18; and
(b) concerns expressed in relation to the risks involved in BBL procedures by a task force established under the auspices of the Aesthetic Surgery Education and Research Foundation (ASERF); and
(c) a voluntary moratorium declared by the British Association of Aesthetic and Plastic Surgeons (‘BAAPS’)
The Inquest heard evidence that some plastic surgeons in the UK continue to carry out BBL procedures. Furthermore, that Elite Aftercare continue to facilitate other clients to travel to Turkey for the purpose of BBL procedures to be undertaken by surgeons such as ████████.

I am concerned at the lack of intervention and control of BBL procedures by the regulatory authorities in the UK.

(2) In order to make an informed decision as to the wisdom of undertaking effective cosmetic surgical procedures such as BBL, it is important that the person involved receive adequate information regarding the mortality and morbidity risks involved. In order to read and absorb such information it needs to be provided prior to any commitment being made or expense incurred. The Inquest into the death of Ms Cambridge heard that she was provided with a substantial quantity of material (some of which was written in Turkish) on the morning of the surgery and required to sign each page. The Inquest found she had insufficient time to digest this complex material, even if she was in a frame of mind to try, shortly before being taken to theatre. My concern is that informed consent is not obtained.

(3) If BBL procedures continue to be permitted in the UK, I consider there is a need for the regulatory authorities to consider prescribing guidance on the surgical techniques to be employed and the information to be provided before a person incurs expense.