Monique Susanna WHITBREAD · Prevention of Future Deaths report

On 1 April 2014, I commenced an investigation into the death of Monique Whitbread, aged 49 years. The investigation concluded at the end of the inquest on 23 July. The determination I made at inquest was that Monique Whitbread died from a recognised complication of medical treatment.

Ms Whitbread’s medical cause of death was:

1a pulmonary aspergillosis and sepsis;
1b intra abdominal complications related to bariatric procedures;
1c laparoscopic gastric bypass on 09.01.14 for obesity;
2 diabetes mellitus, hypertension.

Ms Whitbread had a body mass index of above 50 and was referred for bariatric surgery. She also had a hernia. Her surgical options were:
- gastric band
- sleeve gastrectomy
- gastric bypass.

You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate, and she died ultimately from the consequences of this.

You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia. Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation.

It seems from your evidence that it would be helpful to disseminate your experience and observations nationally.