Stuart Clarke · Prevention of Future Deaths report

On the 2nd July 2019 an investigation was commenced into the death of Stuart Clarke, aged 82 years, born on the 15th October 1936.

The investigation concluded following the inquest on the 22nd October 2019.

The Medical Cause of Death was:

1a Pulmonary Oedema
1b Left Ventricular Dysfunction

II Complications of Aortic Valve Procedure, Coronary Artery Disease and Hypertension.

The conclusion at the inquest was:

Narrative Conclusion: Stuart Clarke died as a consequence of naturally occurring disease, exacerbated by complications arising out of an aortic valve procedure.

1. In February 2018, Stuart Clarke presented at his GP with symptoms of breathlessness. However, it was not until the 25th June 2019 (16 months later) that Mr Clarke finally underwent necessary Transcatheter Aortic Valve Implantation (TAVI) at Wythenshawe Hospital.

2. Evidence was heard from the Consultant Cardiologist at Wythenshawe Hospital, who carried out the TAVI procedure on the 25th June 2019. She confirmed that this overall pathway from onset of symptoms to treatment in Mr Clarke’s case was unacceptably long. In the event, Mr Clarke did not recover following the procedure on the 25th June 2019 and his condition declined, leading to his death at Wythenshawe Hospital on the 27th June 2019.

In evidence, the Consultant Cardiology expressed the view that – had the procedure been carried out in a timelier manner – the outcome might have been different for Mr Clarke. She could not say if the outcome would have been different on the balance of probabilities.

3. The Consultant Cardiologist explained that the normal patient journey would involve referral by the GP to the local hospital. In the present case, Mr Clarke was referred to Cardiology at Royal Oldham Hospital. It is then for the local hospital (in this instance, Royal Oldham Hospital) to refer to the tertiary centre (in this case, Wythenshawe Hospital) for specialist assessment. Mr Clarke was not seen at Wythenshawe Hospital until January 2019. It then took a further 5 months for his suitability for TAVI to be confirmed and then for the procedure to take place.

By the time that Mr Clarke underwent the TAVI procedure on the 25th June 2019 he had deteriorated and was significantly less well than he had been in the months following his initial presentation to his GP in February 2018. During the course of the inquest, I heard that steps are being taken at local level to ensure more timely intervention in similar cases. However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valvular disease.