Samsam Haji Ali Ateye · Prevention of Future Deaths report

An investigation was commenced into the death of Samsam Haji Ali Ateye, aged 68. The investigation concluded on 30 August 2024. The conclusion in the inquest was:

Complications following surgical procedure.

The medical cause of death was

1a Multiorgan failure
1b Following bio prosthetic aortic valve replacement surgery
1c Aortic stenosis with ventricular hypertrophy and fibrosis
II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia

Samsam died on 12 May 2023 at Harefield Hospital, Uxbridge. She had been diagnosed with severe aortic stenosis which was symptomatic. A Multi-Disciplinary Team (MDT) meeting decided that she would benefit from aortic valve replacement surgery. She had an out-patient pre-operative Covid-19 Polymerase Chain Reaction (PCR) test performed on 18 April 2023, which was negative. She was admitted to hospital on the day of her surgery on 20 April 2023. On admission, she had another Covid-19 PCR test performed on her that morning, before her surgery. She had aortic valve replacement surgery that afternoon. Post-operatively, the surgeons who operated on her became aware, that evening, that the Covid-19 PCR test performed on her on the morning of surgery was positive. A subsequent three further Covid-19 tests performed in hospital after 20 April 2023 were also positive. Post-operatively, she developed episodes of atrial fibrillation, as well as sepsis which was probably bacterial and was of unknown origin. She died due to sepsis which caused Multi-Organ Failure. The inquest heard evidence that the consultant surgeon was very worried upon learning that Samsam was Covid positive as patients who are Covid positive who undergo cardiac surgery have a real risk of excessive complications and mortality. The inquest heard that policy about pre-operative testing for Covid for cardiothoracic surgery and the form of that testing was formulated at a national level by NHS England.

1. The policy for testing for Covid-19 before cardiac surgery, specifically valve replacement surgery..