Muriel Ann Brett · Prevention of Future Deaths report

On 29 March 2016 I commenced an Inquest into the death of Muriel Ann Brett, 69. This concluded at the end of the Inquest hearing on 26 April 2017. The conclusion of the inquest was that Muriel had died from a known but rare complication of an elective surgical procedure. The medical cause of death was given as :
1 (a) Right Pneumonia;
1 (b) Perforated Oesophagus (stented);
1 (c) Valvular Heart Disease (Operated 11 March 2016 and 12 March 2016)

Muriel suffered with severe aortic stenosis. She underwent an aortic valve replacement procedure on 11 March 2016. At surgery the first replacement valve was felt by the operating Surgeon to be defective. It was explanted and a second replacement valve then implanted.

Muriel underwent a second operation on 12 March 2016 at which time blood and clots were removed to prevent the risk of cardiac tamponade.

Muriel underwent three transoesophageal echocardiographs (TOE) on different dates by different clinicians.

On 20 March 2016 an oesophageal perforation was identified which was stented. I found that it was more likely than not that the cause of the perforation was the insertion of the probe at one of the TOE procedures. It was not possible to say from the evidence which examination had caused the perforation. Muriel sadly deteriorated and died in Derriford Hospital, Plymouth on 20 March 2016.

Subsequent investigation carried out independently on behalf of Edwards Lifesciences (of the explanted valve) had been unable to identify any defect with it.

[(1) It is of concern that a valve implanted at cardiac surgery was felt by the operating surgeon to be defective;
(2) It is further of concern that an independent review of the explanted valve did not reveal a defect, in contrast to the view of the operating surgeon.