On 11th May 2015, opened an inquest into the death of: Rosina Drury, who died on 21st October 2013 in Kings College Hospital, Case Ref:_ Her medical cause of death was: 1a fat embolism 1b Bone cement implantation II Fractured right femur (operated): It was concluded that she died of unintended consequences of necessary medical treatment,

Evidence was heard that: The deceased had ischaemic heart disease (a myocardial infarct in 2009), atrial fibrillation (on Warfarin) , hypertension recentiy recovered chest infection and diabetes, but she was fit and although unsteady, independent She fell, fracturing her hip. A right hemia-rthroplasty was chosen and she died of a rare complication; Evidence was heard from the consultant orthopaedic surgeon that uncemented arthroplasties, that avoid fatalities from bone cement implantation, although an embolus is still possible), achieve less good pain control, result in slower mobilization and have a higher mortality at 30 days, The surgeon said that he did not choose the uncemented technique unless the patient was immobile. This remained the position even if there was a history of pulmonary embolus _ The expert opinion read, from identified that good practice in prevention was pre-operative review within four hours of admission by an orthogeriatrician;, to assess and manage multiple co-morbidities_ This did not happen in this case and only occurs if surgeon considers a referral was needed. It was also heard scientific literature that bone cement implantation should be avoided in high risk cases. She was reviewed prior to surgery by a consultant anaesthetist with appropriate seniority, another of recommendations.

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