Michael Thompson

I am Louise Hunt for Birmingham and Solihull

On 22 August 2024 I commenced an investigation into the death of Michael John THOMPSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Died  from a recognised complication of necessary surgery for chondrosarcoma

Mr Thompson was found to have an extensive chondrosarcoma of the pelvis. He was admitted to  the Royal Orthopaedic hospital on 05/04/24 and had a right sided hindquarter amputation and soft tissue reconstruction on 08/04/24. This was complex surgery involving two consultant orthopaedic  oncology surgeons and plastic surgeons. During the surgery a defect was made in the peritoneum  during resection of the tumour which was repaired with sutures and bleeding was controlled from  the internal iliac vein. There was damage to the contralateral common iliac vein likely caused by  dissection during the surgery. This vein injury was difficult to control and required surgeons to  attend from University Hospital Birmingham who repaired the defect with a synthetic vascular graft. The surgery was completed and as he was unstable Mr Thompson was transferred to the Queen  Elizabeth Hospital ITU for 4 days for resuscitation and closer monitoring. He returned to the Royal  orthopaedic hospital on 12/04/24 and appeared to be making good recovery. He developed hiccups overnight on 15/16th April which were treated medically with a plan to arrange a CT scan if this did not resolve. In the early hours of 18/04/24 he sadly collapsed having had a large vomit and  should not be resuscitated. Post-mortem examination found a defect in the peritoneum through  which small bowel had become herniated leading to vomiting and aspiration. Following a post mortem the medical cause of death was determined to be: 1a ASPIRATION 1b   INTERNAL HERNIA WITH SMALL BOWEL EXTENDING THROUGH A DEFECT IN THE PERITONEUM INTO THE SURGICAL BED 1c HINDQUARTER AMPUTATION FOR CHONDROSARCOMA 1d II

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. During the surgery on 08/04/24 a defect was made in the peritoneum whilst dissecting this  away from the tumour and the defect was repaired with sutures. The operation note did not record this complication and other staff were unaware of it. This raises a concern about the adequacy of record keeping in the Trust as a key aspect of the patient’s surgery was not  recorded.
2. Under the PSIRF process a PSII investigation was undertaken however this only dealt with resuscitation efforts and did not address the peritoneal defect and its repair which was the  root cause of Mr Thompson’s death. This raises a concern about the adequacy of  investigations being undertaken by the Trust and their ability to learn from deaths.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.