On 3rd October 2018 I commenced an investigation into the death of Mrs Surekha Pandharinath Shivalkar aged 78 years. The investigation concluded at the end of the inquest on 24th December 2021 . The conclusion of the inquest was that Mrs Shivalkar, died from; 1 a. Multi-organ Failure 1 b. Complications arising during anaesthesia and hip revision surgery leading to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. A narrative conclusion was arrived at incorporating a finding of unlawful killing . CIRCUMSTANCES OF THE DEATH Mrs Surekha Pandharinath Shivalkar Was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Mrs Shivalkar had a number of serious debilitating comorbidities including ischaemic heart disease, osteoporosis, and chronic obstructive pulmonary disorder. No formal assessment tool was used in the calculation of risk of death, consequently, an inaccurate risk of mortality was assessed as being less than 5%. Mrs Shivalkar was deemed suitable for surgery at a surgical centre that did not have high dependency unit facilities suitable for dealing with the critically ill patient in recovery. On 28 September 2018 Mrs Shivalkar underwent revision total hip replacement surgery under combined regional and general anaesthesia. The surgery was estimated to last 4 to 5 hours. The surgery was completed after a period greater than 7 ½ hours. During surgery, allowed Mrs Shivalkar to sustain a prolonged and dangerous period of hypotension. The anaesthetist failed to communicate this fact to the surgical team. After six hours of surgery, the anaesthetist was specifically asked if there was any reason that surgery ought not to be prolonged, the anaesthetist assented to the delay. Mrs Shivalkar was returned to recovery where she was found to be in a dangerously hypotensive state. The consultant anaesthetist assessed Mrs Shivalkar and failed to recognise her critical state, the patient was discharged from the recovery room. Upon being returned to the surgical ward, Mrs Shivalkar sustained a cardiac arrest, CPR was commenced and steps were taken for transfer to the local intensive treatment unit. Due to the remote location of the surgical centre there were delays in this transfer. Upon admission to the intensive treatment unit Mrs Shivalkar was found to be in multiorgan failure with a profound metabolic acidosis. Despite the efforts of the intensive treatment team Mrs Shivalkar sustained a further cardiac arrest and died. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy chanqes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool.
2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen.
3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.

Mrs Surekha Pandharinath Shivalkar Was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Mrs Shivalkar had a number of serious debilitating comorbidities including ischaemic heart disease, osteoporosis, and chronic obstructive pulmonary disorder. No formal assessment tool was used in the calculation of risk of death, consequently, an inaccurate risk of mortality was assessed as being less than 5%. Mrs Shivalkar was deemed suitable for surgery at a surgical centre that did not have high dependency unit facilities suitable for dealing with the critically ill patient in recovery. On 28 September 2018 Mrs Shivalkar underwent revision total hip replacement surgery under combined regional and general anaesthesia. The surgery was estimated to last 4 to 5 hours. The surgery was completed after a period greater than 7 ½ hours. During surgery, allowed Mrs Shivalkar to sustain a prolonged and dangerous period of hypotension. The anaesthetist failed to communicate this fact to the surgical team. After six hours of surgery, the anaesthetist was specifically asked if there was any reason that surgery ought not to be prolonged, the anaesthetist assented to the delay. Mrs Shivalkar was returned to recovery where she was found to be in a dangerously hypotensive state. The consultant anaesthetist assessed Mrs Shivalkar and failed to recognise her critical state, the patient was discharged from the recovery room. Upon being returned to the surgical ward, Mrs Shivalkar sustained a cardiac arrest, CPR was commenced and steps were taken for transfer to the local intensive treatment unit. Due to the remote location of the surgical centre there were delays in this transfer. Upon admission to the intensive treatment unit Mrs Shivalkar was found to be in multiorgan failure with a profound metabolic acidosis. Despite the efforts of the intensive treatment team Mrs Shivalkar sustained a further cardiac arrest and died.