MARY ANNE MELLOR · Prevention of Future Deaths report

O 28 September 2020 an investigation was commenced into the death of MARY ANNE MELLOR (dob 25 May 1941). The investigation concluded at the end of the inquest on 4 May 2021.

The narrative conclusion of the inquest was:
Mary Mellor died on 25 September 2020 at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent inserted 4 years previously.

(1) Mary Mellor (MM) was found to have a mega aorta in 2012, for which she underwent an aortic valve replacement and replacement of the aortic root/ ascending aorta in Manchester.

(2) Her disease progressed and in 2016 she underwent staged surgery at Liverpool Heart and Chest Hospital (LHCH) with (i) replacement of the aortic arch and placement of a ‘frozen elephant trunk’ (FET) stent followed by (ii) thoracic endovascular aortic repair (TEVAR) extension of the FET to seal the stent in the distal aorta. The surgery went well.

(3) Thereafter MM underwent annual surveillance with CT scanning. Scans in 2019 (reported by an external agency, Medica) and 2020 (reported at LHCH) were reported as showing ‘no leak’, but in retrospect both showed a distal leak. 3D reconstruction was not used to report the scans – had it been, the leak would have been identified and further management (elective surgery or conservative measures) could have been discussed/ planned.

(4) Whilst the evidence suggested that MM may have declined elective surgery, she was deprived of the opportunity to make an informed decision and of planning for the future.

(5) In September 2021 MM became acutely unwell and died of a ruptured thoracic aortic aneurysm, caused by the (unidentified) distal leak from the aortic stent. Emergency surgery would have been associated with significant mortality and morbidity; MM was treated palliatively.

(1) Following a thorough investigation, I HCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported. LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of the date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future.

(2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur.