Muriel Brett
PFD Report
Historic (No Identified Response)
Ref: 2017-0150
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_
[(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_
Sent To
- MRHA
Response Status
Linked responses
0 of 1
56-Day Deadline
10 Oct 2017
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.