Melissa Kerr
PFD Report
All Responded
Ref: 2023-0330
All 1 response received
· Deadline: 8 Nov 2023
Coroner's Concerns (AI summary)
Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon consultation.
View full coroner's concerns
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.
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.
Responses
Action Planned
The Department of Health and Social Care is investigating global medical tourism, including visiting Türkiye to discuss regulatory frameworks and protections for UK nationals, and is considering how to better communicate the risks of medical treatment abroad. (AI summary)
The Department of Health and Social Care is investigating global medical tourism, including visiting Türkiye to discuss regulatory frameworks and protections for UK nationals, and is considering how to better communicate the risks of medical treatment abroad. (AI summary)
View full response
Dear Mrs. Lake,
Thank you for your letter issued on 13 September 2023 to the Secretary of State for Health and Social Care about the death of Melissa Hannah Kerr. I am replying as Minister for Mental Health and Women’s Health Strategy.
Firstly, I would like to say how deeply saddened I was to read of the circumstances of Melissa’s death. I can appreciate how distressing her unexpected death must be for family and loved ones, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to her in order to prevent future deaths.
My officials are investigating the issues surrounding global medical tourism. Our efforts to understand the consequences of international health tourism are global, but we have a strong interest in Türkiye given the number of UK nationals travelling to the country for medical treatments.
The Department has been consulting with the Foreign, Commonwealth and Development Office, NHS England, the Devolved Governments and other relevant stakeholders to obtain a better picture of the impact of medical tourism on patient safety and the NHS. My officials will also be visiting Türkiye shortly to meet with their counterparts. The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future.
Specifically, I have noted in your report the lack of standard pre-assessment questions provided to Ms Kerr in Türkiye. We remain aware countries providing healthcare tourism often conduct pre-assessment checks that may not match UK regulatory standards and we want to encourage all providers treating UK nationals to meet international best practices on pre-operative procedures whenever possible. Such transparency and standardisation are important to reduce potential risks to patients and improve patient care in the UK and overseas.
It is particularly important that those considering having the ‘Brazilian Butt Lift’ (BBL) procedure are made fully aware of the risks and have time to reflect fully on their decision ahead of surgery. As you note in the report, the risks associated with this procedure are high. The risk of death for BBL surgery is at least 10 times higher than many other cosmetic procedures, and it has the highest death rate of all cosmetic procedures. As you note, the British Association of Aesthetic Plastic Surgeons (BAAPS) has advised its members not to carry out Brazilian butt lift surgery until more is known about safer techniques for the procedure.
The Government is considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks ahead of surgery and understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home.
I hope this response is helpful in setting out how seriously the UK Government is taking the issues raised in your report.
Thank you for your letter issued on 13 September 2023 to the Secretary of State for Health and Social Care about the death of Melissa Hannah Kerr. I am replying as Minister for Mental Health and Women’s Health Strategy.
Firstly, I would like to say how deeply saddened I was to read of the circumstances of Melissa’s death. I can appreciate how distressing her unexpected death must be for family and loved ones, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to her in order to prevent future deaths.
My officials are investigating the issues surrounding global medical tourism. Our efforts to understand the consequences of international health tourism are global, but we have a strong interest in Türkiye given the number of UK nationals travelling to the country for medical treatments.
The Department has been consulting with the Foreign, Commonwealth and Development Office, NHS England, the Devolved Governments and other relevant stakeholders to obtain a better picture of the impact of medical tourism on patient safety and the NHS. My officials will also be visiting Türkiye shortly to meet with their counterparts. The intention is to discuss the regulatory framework, and the protections that are in place for UK nationals, and to identify concrete areas where the UK and Turkish authorities should work together to reduce the risks to patients in the future.
Specifically, I have noted in your report the lack of standard pre-assessment questions provided to Ms Kerr in Türkiye. We remain aware countries providing healthcare tourism often conduct pre-assessment checks that may not match UK regulatory standards and we want to encourage all providers treating UK nationals to meet international best practices on pre-operative procedures whenever possible. Such transparency and standardisation are important to reduce potential risks to patients and improve patient care in the UK and overseas.
It is particularly important that those considering having the ‘Brazilian Butt Lift’ (BBL) procedure are made fully aware of the risks and have time to reflect fully on their decision ahead of surgery. As you note in the report, the risks associated with this procedure are high. The risk of death for BBL surgery is at least 10 times higher than many other cosmetic procedures, and it has the highest death rate of all cosmetic procedures. As you note, the British Association of Aesthetic Plastic Surgeons (BAAPS) has advised its members not to carry out Brazilian butt lift surgery until more is known about safer techniques for the procedure.
The Government is considering how we can most effectively communicate with those considering medical treatment abroad, to ensure people are better informed about the risks ahead of surgery and understand the need to ensure appropriate aftercare, including considering when it may be safe to travel home.
I hope this response is helpful in setting out how seriously the UK Government is taking the issues raised in your report.
Sent To
- Department of Health and Social Care
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56-Day Deadline
8 Nov 2023
All responses received
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