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recurance

Reginald Smith

21 Jan 2025 · Coroner Richard Middleton · Dorset

The coroner's concerns

  1. 1. deformed jig

    “Each jig is used many times in surgery having been sterilised after each procedure. It is hammered into the thigh bone and on this occasion may have become deformed over time.”
  2. 2. lost jig

    “The jig was sent away to the manufacturer for analysis but was lost and so no information was available to the court in relation to its integrity.”
  3. 3. lack of quality control

    “There is no quality control in place in relation to the examination of the jigs being used (other than when it is assembled in theatre by a nurse) prior to surgery. There is no auditing/ spot checks in relation to the integrity of the jigs.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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