Mrs Shivalkar was a 78-year-old patient with debilitating co-morbidities scheduled for elective revision hip surgery at a stand-alone surgical unit without Level 2 or 3 care facilities.
The surgical procedure was prolonged, and intraoperatively there was prolonged significant hypotension. In recovery this hypotension continued, but despite this the patient was discharged to the ward, where she sustained cardiac arrest.
After delayed transfer to a facility with critical care, she was found to be in multiple organ failure with a profound metabolic acidosis, leading to a further cardiac arrest from which, tragically, she died.
The coroner, finding concerns regarding preoperative risk assessment and poor communication between the surgical team and anaesthetist, issued a Report to Prevent Future Deaths to the RCoA and the Royal College of Surgeons for action.