Advising with empathy and experience

Woman dies after heart valve inserted wrong way round.


A woman died after surgery because a doctor inserted a heart valve the wrong way round, an inquest heard.

Sheila Hynes, 72, who suffered from rheumatic heart disease, died days after surgery at Newcastle's Freeman Hospital, which admitted the error, in 2015.

The operation to replace two heart valves was intended to improve the quality of her life and extend it.

However, one of the valves was inserted the wrong way round, and the damage from this, combined with her existing heart condition, led to her death.

Surgeon, Asif Shah, told the inquest he had to reinsert the new aortic valve after a stitch cord snapped.

He said: "The procedure was going OK until the very last moment when I was tying down the mechanical valve and the stitch cord snapped."

Mr Shah, who the inquest heard had carried out more than 350 open-heart operations since starting at the Freeman in January 2015, said he gave the valve to a nurse to hold as he prepared to re-fit it.

But the valve was then placed on its mounting the wrong way round, something he said he was unaware could happen.

Two attempts were then made to re-start Mrs Hyne's heart but both times tears were found in a ventricle and she suffered massive internal bleeding.

Mrs Hynes, a great-grandmother, had complained of shortness of breath and the operation to replace the aortic and mitral valves was aimed at relieving her symptoms and extending her life.

Mr Shah said the operation had been brought forward because Mrs Hynes' grandson was getting married later that year and her sister was terminally ill.

Coroner, Karen Dilks, Tyneside’s first female coroner,  recorded a narrative verdict, and said that opportunities to identify and rectify the mistake were missed.

She said she would write to the health trust and to the regulatory body with a view to speeding up a redesign of the valve mounting that would prevent it being held in an inverted position.

Newcastle upon Tyne Hospitals NHS Foundation Trust said that the incident was a "one in a million complication” and that it had made necessary changes to its procedures and protocols so it could not recur.