Hireiti Kuflesion

On 25"h February 2015 commenced an investigation into the death of Hireiti Kufletsion. The investigation concluded at the end of the inquest on 13"h October 2015. The medical cause of death was Multi Organ Failure due to Acute Thrombosis of mechanical mitral valve in the first trimester of pregnancy due to emergency cardiac surgery for acute decompensation due to rheumatic mitral valve disease after previous pregnancy. The conclusion of the Inquest was that death was a result of complications from the presence of a mechanical mitral valve during pregnancy that was compounded by a series of failures in medical care

The deceased passed at the Queen Elizabeth Hospital Birmingham on the 2Oth November 2014 as a result of thrombosis of a mechanical mitral valve The deceased had undergone surgery for the placement of a mechanical mitral valve at the Queen Elizabeth Hospital in January 2012 for rheumatic valve stenosis. She was therefore on warfarin therapy and had been advised to avoid pregnancy The deceased had found she was pregnant in October 2014 and following detailed consideration and advice at the joint Cardiac/Obstetric Clinic run by Consultant Cardiologist; and Consultant Obstetrician, at the Birmingham Women's Hospital on the 11 November 2014 had decided to proceed to termination of her pregnancy at 8 weeks gestation, the of the termination being deliberately planned to minimise complications. However; following admission to the Birmingham Heartlands Hospital on the 12th November 2014 in respiratory distress there were failures on the part of the cardiology team to adequately investigate complications of the mechanical valve, namely: (a) an urgent trans thoracic echocardiogram was not performed on the 13th November 2014; (b) when trans thoracic echocardiogram was performed on the 14th November 2014 it did not adequately view the mitral valve and could not be safely interpreted as excluding a problem with the valve; (c) the trans thoracic echocardiogram was misleading reported verbally and in writing as showing right heart failure secondary to a respiratory condition; (d) a consultant review andlor advice from Cardiologists at the University Hospital of Birmingham were not sought away timing

It is likely that with full investigation of mitral valve function the diagnosis of thrombosis would have been made on the 13th or 14th November 2014 When the diagnosis was made on the 17th November 2014 the deceased was too ill for surgery: With diagnosis earlier it is likely that the deceased would have been transferred to the Queen Elizabeth Hospital and surgery could have been undertaken and death would have been avoided. Failures of clinicians at the Birmingham Heartlands Hospital to prescribed adequate doses of clexane between the 28th and 11th November and the 12th and 14th November 2014 contributed to the development of the fatal thrombosis

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: A review is required of the current local guidelines, recommendations and procedures for the provision of advice from_ where necessary referral to, the joint Cardiac-Obstetric Clinic operated by UHB and BWH: