Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 13
Determining
ReliabilityInquest
in Clinical
“Medical misadventure”
Conclusion: What
are the
Implications
Negligence
Litigation
– Evidential
for
Surgeons
and Clinics?
andPlastic
Expert
Considerations
by Tracy Sell-Peters
At a recent inquest into the death of patient AR who
died following elective cosmetic surgery, a Coroner
reached a relatively rare conclusion, that she died as
a result of “medical misadventure”.
Live evidence was heard from the consultant surgeon,
two clinic nurses, and the anaesthetist, as well as the
resident medical o昀케cer from the private hospital
where the surgery took place. The Coroner agreed
with the pathologist’s 昀椀ndings and concluded that
the care provided had been appropriate, including
the advice and practices in relation to mitigation
of risk of DVT/PE, the surgery itself, the postoperative period, and discharge. Follow-up care was
also appropriate and, although the patient su昀昀ered
post-operative pain, nausea, and constipation, these
were in keeping with the surgery and there were no
concerns about leg swelling or shortness of breath.
Keystone Law’s Healthcare Litigation Partner Tracy
Sell-Peters represented the Consultant Plastic &
Aesthetic Surgeon, and the clinic where he worked,
at the inquest into this tragic death. In this article,
Tracy explains the impact this decision has for
plastic surgeons and clinics.
The Case Facts
The patient underwent abdominoplasty, bilateral
breast reduction, and fat grafting. These are all
procedures which are regularly carried out at
private hospitals and clinics throughout England &
Wales.
After examining all the evidence, the Coroner
reached a short-form conclusion of “medical
misadventure”, the patient having developed a PE in
her right leg veins. Here the conclusion was certainly
appropriate, given that this was a case where there
was an unforeseen or unintended injury or adverse
outcome from elective medical treatment.
The inquest was heard at Westminster Coroners’
Court at the end of August 2025. AR had died
twelve days post-operatively. The post-mortem
identi昀椀ed the medical cause of death as Ia)
pulmonary thromboembolus (PE), Ib) deep venous
thrombosis (DVT), and II) recent surgery. AR did
receive preventative anti-thrombotic treatment
with heparin, even though this is not required or
universally used after plastic surgery procedures.
She exhibited virtually no symptoms of DVT until
the night before her death.
What is “medical misadventure”?
“Medical misadventure” is not a 昀椀nding of fault or
negligence: it is essentially a neutral 昀椀nding. But it
does acknowledge that a recognised complication of
medical treatment has occurred with unintended,
fatal consequences. The option of reaching this
conclusion is highlighted at paragraph 47 of the
Chief Coroner’s Guidance Chapter 15 on Conclusions
(dated 1.1.25). The guidance clari昀椀es that
This is one of a number of fatal cases where death
from DVT/PE has followed surgical procedures for
which anti-coagulation is not mandated but where
death has still ensued even when it is given. Clearly,
the clinical judgement about whether to prescribe
anti-coagulant medication is a very delicate
balancing act for surgeons in these situations. These
cases have rightly provoked widespread discussion.
EXPERT WITNESS JOURNAL
“
‘medical misadventure’ might be the conclusion when
a recognised complication of an elective surgical
procedure has come about with fatal consequences.”
In light of this relatively recent clari昀椀cation,
“medical misadventure” may become more common
as an inquest conclusion.
10
DECEMBER/JANUARY 2025-2026
