Source · Prevention of Future Deaths

Muriel Brett

Ref: 2017-0150 Date: 4 May 2017 Coroner: Andrew Cox Area: Plymouth Torbay and South Devon Responses identified: 0 / 1 View PDF

There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

Date 4 May 2017
56-day deadline 10 Oct 2017 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.
View full coroner's concerns
In the circumstances it is my statutory to report to you: Derriford Park; Derriford Business Park; Plymouth, PL6 5QZ Tel 01752 204636 Fax The duty

[(1) It is of concern that a valve implanted at cardiac surgery was felt by the operating surgeon to be defective; (2) It is further of concern that an independent review of the explanted valve did not reveal a defect; in contrast to the view of the operating surgeon: Please now find enclosed copies of the following: Statement of_ consultant Surgeon Report entitled "Evaluation of CER 2016 02926-1 Model 3300TFX Sixe 21 Carpenter-E's Pericardial Aortic Bio prosthesis prepared by_ dated November 10 2016; Note of telephone conference dated 7 February 2017_

Report sections

Investigation and inquest
On 29 March 2016 | commenced an Inquest into the death of Muriel Ann Brett; 69. This concluded at the end of the Inquest hearing on 26 April 2017. The conclusion of the inquest was that Muriel had died from a known but rare complication of an elective surgical procedure. medical cause of death was given as (a) Right Pneumonia; (b) Perforated Oesophagus (stented); (c) Valvular Heart Disease (Operated 11 March 2016 and 12 March 2016)
Circumstances of the death
Muriel suffered with severe aortic stenosis. She underwent an aortic valve replacement procedure on 11 March 2016. At surgery the first replacement valve was felt by the operating Surgeon to be defective. It was explanted and a second replacement valve then implanted. Muriel underwent a second operation on 12 March 2016 at which time blood and clots were removed to prevent the risk of cardiac tamponade Muriel underwent three transoesophageal echocardio graphs (TOE) on different dates by different clinicians. On 20 March 2016 an oesophageal perforation was identified which was stented. found that it was more likely than not that the cause of the perforation was the insertion of the probe at one of the TOE procedures. It was not possible to say from the evidence which examination had caused the perforation: Muriel sadly deteriorated and died in Derriford Hospital, Plymouth on 20 March 2016. Subsequent investigation carried out independently on behalf of Edwards Lifesciences (of the explanted valve)had_been unable_to identify any defect with it
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you Medicines Regulatory Healthcare Authority have the power to take such action.

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Report details

Reference
2017-0150
Date of report
4 May 2017
Coroner
Andrew Cox
Coroner area
Plymouth Torbay and South Devon

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Oct 2017 (estimated).

Sent to

MRHA

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