Melissa Hannah Kerr · Prevention of Future Deaths report

On 09 December 2019 I commenced an investigation into the death of Melissa Hannah KERR aged 31. The investigation concluded at the end of the inquest on 12 September 2023.

The medical cause of death was:
1a) Pulmonary Thromboembolism and Fat Embolism
1b) Elective Cosmetic Surgery (Gluteal Augmentation)
1c)
2)

The conclusion of the inquest was:
Melissa Kerr followed cosmetic surgery to the thigh and buttock area on 19 November 2019. Ms Kerr was not seen by a surgeon or clinician prior to the date of the procedures. Ms Kerr underwent a limited assessment prior to the procedures. Ms Kerr was provided with limited information regarding the risks and mortality rate associated with the procedures. There is limited documentary evidence as to the procedures performed. Certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat embolus occurring, namely the choice of access incision for the augmentation cannula and the decision to inject fat into the superficial muscle.

Melissa Kerr was admitted to Private Medicana Kadikoy Hospital, Istanbul on 19 November 2019 and underwent surgery to harvest fat from the abdomen, thighs and the jowl area of her face. Ms Kerr was not seen by a surgeon or clinician prior to the 19 November 2019. Evidence revealed that Ms Kerr underwent a limited assessment prior to the procedures. The evidence is that Ms Kerr was provided with limited information regarding the risks and mortality rate associated with the procedures. The fat was collected and processed before it was injected into her buttocks; a liposuction procedure and a Brazilian Buttock Lift procedure. During surgery Ms Kerr became unwell. Her condition deteriorated and she was declared dead. There is limited documentary evidence as to the procedures performed. Expert evidence was heard that certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat embolus occurring, namely the choice of access incision for the augmentation cannula and the decision to inject fat into the superficial muscle.

1. Expert evidence was heard that the findings in this case are consistent with findings in other cases where patients have died following autologous fat transfer to the gluteal area during an operation colloquially known as Brazilian Buttock Lift. I understand from the evidence heard that due to the high mortality associated with this procedure a voluntary moratorium on the practice of this procedure has been introduced in the UK. Recommendations for safer practices have emerged that recommend significant changes to practice.
2. I am concerned that patients travelling to Turkey for this procedure are not being made aware of the risks and the high mortality rate associated with this surgery
3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place. Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure. There was limited psychological and physical assessment prior to the procedure proceeding.
4. I appreciate the UK Government has no control over what happens abroad. However I am concerned that citizens are travelling abroad for such procedures unaware of the risks involved and that practices are used which are regarded as unsafe in the UK.