ANN COLES · Prevention of Future Deaths report

An investigation into the death of Ann Coles was opened on the 4th April 2019. The Inquest was opened on 12th November 2019 and resumed and concluded on 16th March 2021.

I concluded that Ann Coles was admitted to Frimley Park Hospital suffering with severe bilateral pneumonia and sepsis. Despite appropriate treatment she developed multi-organ failure and died on the 12th March 2019. The cause of death was:

I a Multiple Organ Failure
I b Sepsis
I c Pneumonia
II Aortic Stenosis

I concluded she died of natural causes

Ann had a tissue aortic valve replacement in 2014 having been diagnosed with severe aortic stenosis. She developed atrial fibrillation after the operation and required medication to revert to sinus rhythm. Thereafter she was prescribed amiodarone to prevent her relapsing into atrial fibrillation. She was subject to annual reviews thereafter. In March 2019 she was admitted to Frimley Park Hospital suffering with shortness of breath and found to have developed pneumonia. Despite appropriate treatment she died from multi-organ failure on the 12th March 2019.

The evidence showed that a potential side effect of amiodarone medication is that it can cause toxicity which affects the lungs and can cause fibrotic changes. In her evidence the consultant cardiologist who treated Ann in her final illness raised the concern that there is no requirement for lung imaging to be undertaken when patients are prescribed amiodarone on a long term basis which in her view was a glaring gap in the oversight necessary for the effects of the medication.