KATHRYN BULL, then aged 61 years, died on 4 December 2014. An investigation into her death, and then an inquest was opened The inquest into Mrs Bulls death was resumed, and concluded, by myself on 27 April 2016. The medical cause of Bull's death was:
1.a Multi-organ failure;
1.b Hyperammonaemia syndrome;
1.c Morbid obesity and gastric bypass surgery: The conclusion as to the cause of death was a narrative one to the effect that Mrs Bull died as a result of an extremely rare complication of gastric bypass surgery_

The circumstances of the death are as follows: Bull was morbidly obese_ On medical advice she had had a gastric bypass operation on 19 January 2014.
2) Her immediate post-operative recovery was good and she began a liquid diet: (3) However she gradually found it hard to tolerate the solid food diet that she was advised to follow and often only felt able to eat 2 meals a not 3 (4) She complained of dizziness, lethargy, vomiting 'blacking out'_ These are all unremarkable symptoms of gastric bypass surgery and so did not trigger any concerns in the team monitoring her follow up from the surgery. (5) By October 2014 she was rarely leaving the house. (6) On 19 November 2014 she fell at home and was admitted to Lewisham and Greenwich Hospital The hospital staff were unsure f the cause of her illness but suspected some form of endocrine collapse or failure secondary to prolonged malnutrition and deficiency in trace elements. (8) Her conscious state fluctuated. (9) By 26 November 2014 her ammonia level had risen to 226 pmollL (where a level of 112 pmolIL could lead to a deranged cerebral state) (10)She became less conscious and required intubation, T)She deteroriated further and suffered a cardiac arrest on 4 December 2014, from which she could not be resuscitated, She was pronounced dead at 3.30 pm that Mrs (1) Mrs day and day:

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.