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”.
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 Keynote, 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.
The inquest was heard at Westminster Coroners’ Court at the end of August 2025. AR had died twelve days post-operatively. The post-mortem identified 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.
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.
Live evidence was heard from the consultant surgeon, two clinic nurses, and the anaesthetist, as well as the resident medical officer from the private hospital where the surgery took place. The Coroner agreed with the pathologist’s findings 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 post-operative period, and discharge. Follow-up care was also appropriate and, although the patient suffered 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.
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.
What is “medical misadventure”?
“Medical misadventure” is not a finding of fault or negligence: it is essentially a neutral finding. 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 clarifies that “‘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 clarification, “medical misadventure” may become more common as an inquest conclusion.
The significance for private-sector plastic surgeons, clinics, and medical indemnifiers
Firstly, this case highlights the importance of using specialist lawyers for advice and representation in inquests. The “medical misadventure” conclusion may be most relevant (or perhaps only relevant) to patient deaths that happen after private elective aesthetic and cosmetic surgery, given the wording of the Guidance. Using lawyers with extensive experience of representing plastic surgeons and clinics in inquests is essential to make sure the Coroner has the necessary evidence and submissions to reach the right conclusion. This in turn can be crucial for protecting the legal position and reputation of the plastic surgeon and clinic in tragic cases such as this, including by minimising the likelihood of a referral to the GMC, either by the Coroner or by the family.
A finding of “medical misadventure” will make it more difficult for the family of the deceased to then make a clinical negligence claim alleging shortcomings in the clinical care. While a clinical negligence claim alleging a failure in the consenting process may still be possible, an appropriate inquest finding can significantly reduce the chances of a clinical negligence claim. This can save or minimise the costs involved in a subsequent claim, and the time and stress associated with defending one. Appropriate findings can also minimise the risk of damaging publicity for the surgeon and clinic, which in a competitive market can be vital for protecting their practice.
If you are a medical professional, clinic, or hospital and require advice, please contact Tracy Sell-Peters. Tracy has extensive experience representing healthcare professionals and providers in inquests and many other types of proceedings in England & Wales.