Beryl WALTERS · Prevention of Future Deaths report

On 27 June 2014, I commenced an investigation into the death of Beryl WALTERS. The investigation concluded at the end of the inquest on 11 November 2014. The conclusion of the inquest was the deceased died from 1a. Myocardial Infarction and mitral valve disease; 1b. Coronary artery thrombosis; 1c. Coronary artery atherosclerosis; 2. Cyclizine administration. My conclusion was Natural Causes

1. Mrs Walters presented at A&E with an atypical history of chest pain

2. An ECG showed a posterior Myocardial Infarction.

3. According to the local pathway she was given an antiemetic (Cyclizine) as she reported feeling sick. The pathway did not at that time specify which anti-emetic should be given, and during the evidence heard it transpired that in the hospital concerned, Cyclizine was widely used in these circumstances.

4. Very shortly after the administration of Cyclizine Mrs Walters went very hypotensive and tachycardic, and then suffered a Cardiac Arrest from which she could not be resuscitated.

5. At Post Mortem, there was evidence of severe Right Coronary Artery occlusion by atheroma, with appearances consistent with early infarction in the posterolateral part of the left ventricular wall.

6. The reporting pathologist drew my attention to the existence of a paper from 2006 (attached) the conclusion of which was “Cyclizine should be avoided in patients with acute coronary events”.

7. The hospital concerned has now revised their pathway in the light of these circumstances to advise the use of Metoclopramide as the first line anti-emetic in patients with acute coronary events.

(1) The British National Formulary states in the cautions part of the section on Cyclizine “severe heart failure; may counteract haemodynamic benefits of opioids,...”

(2) The paper attached, whilst itself drawing the reader’s attention to the possible non-transferability of the findings to the emergency department, and the limited group of patients the original 1988 study was based on, makes a recommendation not to use Cyclizine in these circumstances.

(3) The availability of an alternative antiemetic, Metoclopramide, which does not appear to share the same cardiac risk profile, would seem to suggest that the use of Cyclizine is an unnecessary risk in these circumstances.