Monique Whitbread
PFD Report
Historic (No Identified Response)
Ref: 2014-0368
Coroner's Concerns (AI summary)
A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.
View full coroner's concerns
Ms Whitbread had a body mass index of above 50 and was referred for bariatric surgery. She also had a hernia. Her surgical options were:
- gastric band
- sleeve gastrectomy
- gastric bypass.
You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate, and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia. Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation.
It seems from your evidence that it would be helpful to disseminate your experience and observations nationally.
- gastric band
- sleeve gastrectomy
- gastric bypass.
You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate, and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia. Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation.
It seems from your evidence that it would be helpful to disseminate your experience and observations nationally.
Sent To
- University College Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
24 Sep 2014
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 1 April 2014, I commenced an investigation into the death of Monique Whitbread, aged 49 years. The investigation concluded at the end of the inquest on 23 July. The determination I made at inquest was that Monique Whitbread died from a recognised complication of medical treatment.
Circumstances of the Death
Ms Whitbread’s medical cause of death was:
1a pulmonary aspergillosis and sepsis; 1b intra abdominal complications related to bariatric procedures; 1c laparoscopic gastric bypass on 09.01.14 for obesity; 2 diabetes mellitus, hypertension.
1a pulmonary aspergillosis and sepsis; 1b intra abdominal complications related to bariatric procedures; 1c laparoscopic gastric bypass on 09.01.14 for obesity; 2 diabetes mellitus, hypertension.
Copies Sent To
Professor Dame Sally Davies, Chief Medical Officer for England
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
London Fire Brigade to establish lessons learned process
Grenfell Tower Inquiry
No open learning culture
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.