Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report

During the course of the Inquest I heard evidence from ████████(Consultant Surgeon) who indicated a number of matters which caused me some concern and which I would be grateful if you could look into please in order to prevent future deaths occurring in similar circumstances.

The first of the issues that he raised was the fact that it is quite normal for cardiology review to take anything up to six months to come through to the surgeon proposed to operate on the patient. In this particular instance the first consultation with the surgeon took place on 5 July 2012 and in view of her cardiac history he referred her to the cardiologist for cardiac optimisation review. Report back from the cardiologist came on 28 January 2013. It seems to me unsatisfactory that this length of time should elapse for cardiology reviews in these circumstances.

Secondly the surgeon indicated that the booking of theatres and follow-up therefrom is dealt with by the management and not from any input from the surgeons themselves. ████████ indicated that it was for this reason that there was a delay in booking this lady in to surgery and that delay may have had a bearing on her wellbeing at the time of surgery but more particularly during the recovery period. Again I would have thought that an input from the surgeons would have been the prime consideration that bed managers should be looking at when booking theatres, etc.

Thirdly ████████ indicated that there are simply not enough surgeons dealing with this type of laparoscopic surgery and to deal with the number of patient's requiring their care. They are simply unavailable to perform these operations and therefore the operations are later than would often be desirable and this can of course have quite devastating effects.

Finally he also indicated that they needed to be seeing this type of patient more urgently and again they cannot do this simply because there are insufficient surgeons available for the number of cases that they are expected to deal with.

On a separate issue completely I also heard evidence that the type of clips used to clip blood vessels during the course of an operation have been changed since the death of Mrs Rushworth. I would be grateful if you could confirm that this is the case and also confirm whether or not the original clips were deficient in some way and whether there is a need for further investigations as to the efficacy of the presently used clips.