Freda Mary Lennox · Prevention of Future Deaths report

On 5th May 2021 I commenced an investigation into the death of Freda Mary Lennox. On the 4th October 2021 I concluded the Investigation.

The medical cause of death given was:

1a. Cor Pulmonale
1b. Pulmonary Hypertension
1c. Interstitial Lung Fibrosis

2. Elective Right Hip Replacement

I determined that Freda Mary Lennox died as a consequence of natural causes hastened by an operative procedure

Mrs Lennox was an 86-year-old lady with multiple medical comorbidities with a significant history of idiopathic pulmonary fibrosis which restricted her activities of daily living leaving her house bound and requiring long term oxygen therapy.

Mrs Lennox was initially scheduled and then cancelled for an elective total hip replacement in November 2018 and May 2019 before being admitted to St Peter’s Hospital on 2nd November 2020 for the procedure. She was informed of and understood that this was a high-risk procedure for which she gave consent. At the end of the surgical procedure, she had a cardio-respiratory arrest from which she was initially successfully resuscitated and admitted into the intensive care unit. Despite such support, she did not rally and died at 04.07 hours on 4th November 2020.

1. Mrs Lennox had previous pre-operative assessments in 2018 and 2019 and a respiratory review in February 2020. Following a telephone consultation in September 2020 an echocardiogram was requested to look for pulmonary hypertension and/or the development of Cor Pulmonale but this had not been carried out prior to her surgery.

2. Mrs Lennox had not been recently reviewed by the consultant orthopaedic surgeon prior to her admission on 2nd November 2020 despite her medical co-morbidities having given rise to concerns as to her suitability for an elective total hip replacement.

3. The consultant anaesthetist was not informed about Mrs Lennox and her medical co-morbidities prior to her admission. Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs Lennox consented for surgery.

4. Evidence was heard that there was a lack of funding for a dedicated high-risk consultant led anaesthetic pre-operative assessment clinic with the necessary equipment to be able to suitably risk assess patients prior to any potential surgery.

5. There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service.