Inquest into the death of Madeline Newcombe

Contributing factors

• Bilateral knee arthroplasty in single procedure
• Class 1 obesity (BMI 31.6-33.6)
• General anaesthetic with prolonged tourniquet use (62 minutes right leg, 59 minutes left leg)
• Inadequate discussion of increased thromboembolism risk from bilateral surgery
• Lack of individualised documented risk assessment by surgeon
• Use of aspirin rather than LMWH for chemical prophylaxis
• Lack of multi-modal thromboprophylaxis innovations

Coroner's recommendations

1. The ASOA Guidelines should be clarified to explicitly state that bilateral knee replacement, as opposed to single knee replacement, increases the risk of venous thromboembolism and should be considered as a risk factor in the risk assessment.
2. The ASOA Guidelines should provide a clear definition of 'marked obesity' rather than leaving it to individual interpretation.
3. Surgeons should conduct and document individualised thromboembolism risk assessments prior to surgery, incorporating patient factors (age, fitness, weight, blood constitution) and surgical factors (single versus bilateral replacement).
4. The discussion with patients about the choice between staged single knee replacements versus bilateral replacement in a single procedure should occur at the initial consultation, not on the day of surgery, to allow proper informed consent regarding thromboembolism risks.
5. Multi-modal thromboprophylaxis innovations should become standard practice, including: minimisation of tourniquet use, consideration of spinal rather than general anaesthetic, use of warmed fluids, and early post-operative mobilisation.
6. The timing of sequential compression device application should be optimised to ensure devices are applied as soon as practically possible post-operatively.
7. The use of chemical prophylaxis (LMWH versus aspirin) for knee replacement patients should be individualised based on risk assessment and should incorporate consideration of bilateral surgery as an increased risk factor.