Hireiti Kufletsion · Prevention of Future Deaths report

On 25th February 2015 I commenced an investigation into the death of Hireiti Kufletsion. The investigation concluded at the end of the inquest on 13th October 2015. The medical cause of death was multi Organ Failure due to Acute Thrombosis of mechanical mitral valve in the first trimester of pregnancy due to emergency cardiac surgery for acute decompensation due to rheumatic mitral valve disease after previous pregnancy. The conclusion of the Inquest was that death was a result of complications from the presence of a mechanical mitral valve during pregnancy that was compounded by a series of failures in medical care.

The deceased passed away at the Queen Elizabeth Hospital Birmingham on the 20th November 2014 as a result of thrombosis of a mechanical mitral valve. The deceased had undergone surgery for the placement of a mechanical mitral valve at the Queen Elizabeth Hospital in January 2012 for rheumatic valve stenosis. She was therefore on warfarin therapy and had been advised to avoid pregnancy. The deceased had found she was pregnant in October 2014 and following detailed consideration and advice at the joint Cardiac/Obstetric Clinic run by ████████ Consultant Cardiologist, and ████████ Consultant Obstetrician, at the Birmingham Women’s Hospital on the 11th November 2014 had decided to proceed to termination of her pregnancy at 8 weeks gestation. The timing of the termination being deliberately planned to minimise complications. However, following admission to the Birmingham Heartlands Hospital on the 12th November 2014 in respiratory distress there were failures on the part of the cardiology team to adequately investigate complications of the mechanical valve, namely:
(a) an urgent trans thoracic echocardiogram was not performed on the 13th November 2014;
(b) when trans thoracic echocardiogram was performed on the 14th November 2014 it did not adequately view the mitral valve and could not be safely interpreted as excluding a problem with the valve;
(c) the trans thoracic echocardiogram was misleading reported verbally and in writing as showing right heart failure secondary to a respiratory condition;
(d) a consultant review and/or advice from Cardiologists at the Queen Elizabeth Hospital were not sought.

It is likely that with full investigation of mitral valve function the diagnosis of thrombosis would have been made on the 13th or 14th November 2014.

When the diagnosis was made on the 17th November 2014 the deceased was too ill for surgery. With diagnosis earlier it is likely that the deceased would have been transferred to the Queen Elizabeth Hospital and surgery could have been undertaken and death would have been avoided.

Failures of clinicians at the Birmingham Heartlands Hospital to prescribe adequate doses of clexane between the 28th and 11th November and the 12th and 14th November 2014 contributed to the development of the fatal thrombosis.

(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.