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 level-3 care facilities. Intraoperatively, significant hypotension was poorly recognised and treated. By the time care was escalated, she had developed severe metabolic acidosis and multi-organ failure leading to her death.
The coroner issued a ‘Report to Prevent Future Deaths’ to the RCoA and the Royal College of Surgeons for action. From our review of the available information, the lessons to be learnt by our specialty were related broadly to risk assessment, remote-site working and team working. My previous article (Part 1) addressed the first two areas, while this follow-up article focuses on team working and the role of multidisciplinary team (MDT) training.