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Risk of harm following gastric bypass | Signal

Reference number
Issue date28 February 2012

This Signal addresses the potential for harm to patients following gastric bypass surgery.


A Coroner’s report received by the NPSA concluded that a patient who had undergone gastric bypass surgery died four years later, as a result of a micro-nutrient deficiency, having been lost to necessary follow up. 


An extract from the report reads:

“The patient developed a micro-nutrient deficiency (a recognised complication of the surgery) which was not immediately diagnosed because of its comparative rarity. The deficiency eventually led to multi-system involvement requiring hospital admission and, in particular, the formation of ulcers and pressure sores. All of these matters, but most particularly the micro-nutrient deficiency, left the patient vulnerable to infection and with a reduced immune response. In consequence she developed an over-whelming and unusually rapid septic shock from a lung infection, leading to her death.”


A search of the National Reporting and Learning System has not identified any further patient safety incidents related to micro-nutrient deficiency following gastric bypass surgery. However, as gastric bypass surgery has become more common place over recent years, and because complications following surgery are possibly under recognised, they may be more common than incident reporting suggests.


Following gastric bypass surgery, organisations should ensure:

• All post bariatric surgery patients are followed up for life, either by primary care or by the hospital bariatric team. This follow up must include annual blood tests to ensure no serious vitamin or nutrient deficiencies arise. The blood tests should include full blood count with haematinic markers (ferritin, B12 and folate), liver function tests, parathyroid hormone level, zinc and selenium levels.

• That any patient who has had gastric bypass surgery, and who is not under regular review by the hospital bariatric team, continues to take multivitamin, iron and calcium supplements and any other supplements for life. These should be taken either as advised originally by the hospital bariatric team or as later found necessary on the basis of blood tests.

•  Any patients for whom there are concerns are urgently referred back to the bariatric service where they were treated.


The Endocrine Society provides guidance on Endocrine and Nutritional Management of the post-bariatric surgery patient (2010).  NICE (43) provides guidance on the Prevention, identification, assessment and management of overweight and obesity in adults and children (2006).


We would like to hear from you – please contact us with your initiatives to reduce risks in these areas. We can share them with appropriate forums for example the Clinical Board for Surgical Safety.


Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.