Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals.

East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018.

The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing.

A Barts spokesperson said the trust had made a number of changes after carrying out an investigation.

Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote.

She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder.

But Mr Irvine said an inaccurate risk of death of less than 5 per cent was given, as no formal risk assessment tool was used.

The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure.

He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point.

Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient."

Mrs Shivalkar was discharged to a surgical ward after the anaesthetist failed to recognise her critical low blood pressure, he wrote.

She then sustained a cardiac arrest and was transferred to the intensive treatment unit but there were delays in the transfer, the coroner said.

Mrs Shivalkar later died of multi-organ failure and "complications arising during anaesthesia and hip revision surgery leading to hypotension and hypoperfusion", the inquest found.

Mr Irvine also raised a concern that there was no system in place to effectively monitor when a surgeon leaves theatre.

He wrote that the senior consultant surgeon left the surgery before its end, "lengthening the procedure".

The Barts spokesperson said that among the changes it had made was the introduction of regular training for theatre and recovery teams in the care of deteriorating patients and simulation training in human factors for theatre staff.

Multidisciplinary team meetings also take place for complex orthopaedic operations to decide where they should take place.

They added: “We are deeply sorry to Mrs Shivalkar and her family for the standard of care she received and accept the coroner's conclusion."