Delay led to heart death

George Hill was diagnosed with heart disease after suffering breathlessness and chose the TAVI (Transcatheter Aortic Valve Implantation) procedure, a relatively new alternative to open heart surgery.

A Blackpool Coroner’s Court inquest heard the hospital’s Lancashire Cardiac Centre had now altered TAVI procedures – which corrects the narrowing of the aortic heart valve – following the deaths of Mr Hill and another patient, Enid Smith, from Calder Vale, whose inquest will be held in the New Year.

Mr Hill, of Coppull Hall, Coppull, Chorley, was put under general anaesthetic at 9am on January 14, 2013.

A trained member of staff supervised an untrained senior employee in unsuccessfully attempting to fit the replacement aortic valve onto a catheter. A spare valve was also tried, but that too failed and there were no other valves in stock.

Senior clinical lead Dr David Roberts said this was normal because of the £14,500 cost per valve - especially when the NHS was facing “challenging financial times”.

A TAVI industry representative was often present during the procedure, and sometimes carried spare valves. But he was not there this time as he was on his honeymoon.

Dr Roberts decided against halting the procedure due to the risks associated with doing so, and dispatched a colleague to collect a valve from Wythenshawe Hospital in Manchester, the nearest with any in stock.

The two-and-a-half hour delay meant a wire used to position the valve had to be moved and the oxygen reaching Mr Hill’s brain dipped to levels which suggested he may have suffered a stroke. A clot had formed around the wire, affecting blood supply to the brain. However, Dr Roberts said there was no option but to complete the procedure.

A CT scan showed that Mr Hill had suffered a stroke and he died on February 6, a day after being moved to Cornmill Nursing Home in Garstang.

A post mortem showed he had died as a result of a cerebral thrombosis embolism caused by the surgery.

Dr Roberts accepted that it may have been better to ask someone from Wythenshawe to deliver the valve to save time. He also admitted that in hindsight he wished he had halted the procedure, although he received support for his decision to continue from anaesthetist Dr Michael Hartley and independent Tavi expert from New Cross Hospital in Wolverhampton, Dr Saib Khogali.

Jane Meek, assistant director at the Blackpool Teaching Hospitals NHS Foundation Trust, said changes had been made to procedures following an investigation.

These include reducing clot risk by introducing previously unavailable specialist wires and using higher levels of blood-thinning heparin, and a decision to no longer leave a wire in situ following a delay.

The centre will now use only trained staff to fit valves, although Blackpool and Fylde coroner Alan Wilson (pictured) said he did not blame this for Mr Hill’s death given that a trained employee had also struggled with the procedure.

Mr Hill’s son, George Hill junior, said: “We just hope lessons are learned from this tragic incident. Our main concern is that this does not happen to anyone else.”

Mr Wilson recorded a verdict of death by misadventure.

TAVI was previously not routinely commissioned on the Fylde coast but the North West Specialised Commissioning Group (NWSCG) agreed to fund the pioneering procedure in March 2011 after The Gazette highlighted the plight of desperate patients.