Joan Margaret KNIGHT · Prevention of Future Deaths report

On 11 June 2024 I commenced an investigation into the death of Joan Margaret KNIGHT. The investigation concluded at the end of the Inquest . The conclusion of the inquest was; Died from the consequences of a recognised complication following treatment for severe coronary artery stenosis

Mrs Knight suffered an acute inferior wall myocardial infarction on 16/05/24 and had treatment by way of angioplasty to her right coronary artery with a stent being fitted. The procedure was complicated as she was found to have significant calcium build up in the coronary artery. It was also noted that the left anterior descending artery had severe narrowing. Initially after the procedure she was pain free; however she began to experience further chest pain on 18/05/24 which was treated with medication. The chest pain recurred on 20/05/24 and a further procedure to insert a stent into the left anterior descending artery was undertaken on 21/05/24. During the procedure access was difficult and signification calcification was noted. During ballooning the coronary artery ruptured and was successfully treated with a stent. Whilst initially stable after the procedure her condition deteriorated, and she presented with an unrecordable blood pressure. A bedside echocardiogram confirmed a collection of blood around the heart and an emergency pericardial aspiration was undertaken and she was taken back to the cardiac catheter lab where a covered stent was fitted to try to treat the bleeding at the site of the previous perforation. The bleeding was difficult to control and arrangements were made to transfer her to the Queen Elizabeth Hospital where a CT scan confirmed bleeding in the abdomen. She was taken to theatre where no site for bleeding was found in the abdomen; however a small perforation in the right ventricle was identified and repaired which was likely caused when the emergency aspiration procedure was undertaken. Sadly, she developed multi organ failure in the post operative period and passed away on 25/05/24.

Based on information from the Deceased’s treating clinicians, the medical cause of death was determined to be:

1a Multiple organ failure

1b intrabdominal bleeding from chest compressions and ventricular bleeding secondary to emergency pericardial aspiration (operated)

1c cardiac tamponade

1d treatment for severe stenosis of the left anterior descending coronary artery leading to perforation and bleeding

II Myocardial infarction (treated)

1. The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths.