A woman died after cosmetic surgery when fat from her buttocks was injected into a vein in her face, an inquest heard.
Rachel Soanes, 37, underwent the procedure at St Thomas’ Hospital, Waterloo, to plump out her cheeks.
But in a ‘phenomenally rare’ complication the fat got into her lungs.
Delays mean it was almost two hours before Miss Soanes was admitted into intensive care and minutes later she was dead.
Southwark Coroners’ Court heard Miss Soanes, suffered from the condition lupus profondus, which left her with an usually thin face.
She had undergone the treatment twice before and was admitted to the hospital as an out-patient on February 12 this year.
Shortly after a second re-injection of fat from her buttocks she complained of dizziness and vomited.
Her oxygen levels plummeted but there was a 50 minute delay before a specialist crash team got her.
Nurse Linda Cooper, of the hospital’s patient at risk team the said she was first told about Miss Soanes at 12pm.
But she was in the dermatological out-patients unit and away from the main hospital.
‘The corridor in the unit was too narrow to house a bed,’ she said.
‘There was no recovery area. Out-patients don’t generally require a high level of care after the procedure.’
Ms Cooper said also took time before a hospital trolley could be found for the patient.
‘When we finally arrived the patient’s condition had deteriorated further,’ she said.
Both blood pressure and oxygen levels had continued to fall but Miss Soanes was not admitted into intensive until just before 2pm.
Minutes later she was dead.
Pathologist Professor Sebastian Lucas said Miss Soanes, of Windsor Road, Norwich, died of a fat tissue embolism – one of the first ever documented cases.
This arose from an injection of fat into a vein of her face, he said.
The fat travelled into her lungs and resulting in the embolism, or blockage in the arteries.
Prof Lucas said:‘Once the fat got into the lungs there was nothing anyone could have done.
‘It happened within seconds. There was no way anyone could dissolve or remove the fat. It was all the way through the lobes of the lungs.’
Julie Smithson, Miss Soane’s sister, ask why her sister was not told of the dangers of the proceedure.
Prof Lucas said: ‘It wasn’t a known risk.
‘What happened to your sister was so rare that you wouldn’t mention it to patients.’
Prof Lucas said that he had never seen such an embolism in more than 30 years as a pathologist.
Coroner Dr Harris recorded a narrative verdict.
He said Miss Soanes died from natural causes and medical intervention involving acute respiratory failure brought on by the embolism.
He added that while there had been a delay in giving Miss Soanes treatment nothing could have been done to prevent the ‘phenomenally rare’ complication.
Dr Harris is now considering whether to would write a report to St Thomas’ Hospital about its care of out-patients.
‘My concern is it simply doesn’t seem acceptable that someone who falls critically ill in a hospital has poorer access to emergency treatment than someone outside hospital,’ he said.
‘I’m not suggesting in any way the hospital is blame for the death. I’m simply concerned about out patients who need critical treatment and who may have problems accessing care.’