The family of a woman who died after a surgeon mistakenly implanted a heart valve the wrong way up say the inquest into her death failed to substantially hold him to account for causing her death and has left them asking more questions.
Sheila Mary Hynes, 71, died in intensive care a week after undergoing what her family were assured was routine surgery.
Surgeon Asif Shah, of the renowned Freeman Hospital in Newcastle, has carried out more than 350 open heart operations since starting at the hospital in January 2015 and prior to this week’s inquest.
However, the operation on Mrs Hynes was the first time he had done this particular procedure as the lead consultant.
Surgeon was ‘unaware’ heart valve could be implanted upside down
Mr Shah told an inquest – for which the scope had been extended to allow the coroner to investigate under the Human Rights Act – that the procedure had been ‘going OK’ until the very last moment, when he was tying down the valve and the stitch cord snapped.
He said this meant he needed to remove the valve and hand it to a scrub nurse ready for him to re-fit it. He told coroner Karen Dilks that it was at this stage that the valve must have been placed on its mounting the wrong way round – something he was unaware could happen.
As a result he said he inserted the valve the wrong way round and stitched up Mrs Hynes, who never woke from the operation, as the mistake caused irreversible damage to the left ventricle and her heart.
She died in intensive care a week later, after a second operation to try and get her heart working again failed.
Hospital Trust admits breach of duty as part of ongoing negligence claim
Newcastle Upon Tyne Hospitals NHS Foundation Trust has admitted full breach of duty, and that the error which caused Ms Hynes death was the insertion of the heart valve the wrong way, as part of ongoing legal action taken by the Mrs Hynes family.
In a narrative conclusion, coroner Ms Dilks said she was led to believe that on the balance of probabilities, the valve was remounted incorrectly, and against manufacturers’ instructions.
She also confirmed that once the error had been made there were missed opportunities to identify and correct the damage done by that error, which ultimately led to Mrs Hynes’ loss of life.
She is now to write to the trust to express her concerns that this issue may have potential to cause future problems, and will request that certain areas be addressed.
Legal action will seek ‘civil redress’ for loss and support General Medical Council investigations
At the conclusion of the three-day inquest this afternoon, the family’s lawyer Nicola Evans, of medical negligence specialists Hudgell Solicitors, said that legal action would continue to be pursued.
She revealed that the General Medical Council (GMC) had been in touch with her to confirm they are considering investigating the circumstances of Mrs Hynes death.
She said: “Ever since the tragic and avoidable loss of Sheila in April 2015, her devastated family have battled for answers as to how such a serious, life-taking mistake could be made, and for those responsible to be held to account.
“The inquest scope was extended to give the coroner the ability to thoroughly investigate the circumstances of Sheila’s death by consideration of a breach of a person’s human right to life.
“We welcome today’s narrative conclusion, and the coroner’s comments about writing to the Trust to prevent further situations like this in future. We certainly think there is a need to look carefully at training and use of surgical equipment.
“However, Mrs Hynes family remain of the view that all evidence was not clearly considered, and we will now assist them in seeking civil redress for their loss, and will support the General Medical Council (GMC) with any ongoing investigations.
“Surgeons are aware of the catastrophic results of mistakes such as this, and in this case it has cost a much loved mother, grandmother and great grandmother her life.
“Let us not forget that Sheila’s death was a result of a grave surgical error by Mr Shah. That has been admitted in our legal negotiations, and during this inquest this week.
“I would like to express my thanks to the family for their bravery through such testing times.”
Family vow to continue fighting for justice after inquest concludes
Mrs Hynes daughter, Jan Hopper, of Haltwhistle, Northumberland, says losing her mother in such tragic and unexpected circumstances has ‘destroyed her life too’.
She said: “No matter how many times we hear the reasons for what went wrong and why, we will never be able to overlook the fact that my mother died simply because a highly experienced surgeon didn’t take enough care. It is beyond belief.
“We don’t even know whether to believe the valve was reinserted upside down. We feel Mr Shah was simply incompetent, unsupervised and made a mess of our mother’s heart.
“It was a week after the error, and after my mum had died, that the hospital finally admitted to us that the heart valve had been put in upside down.
“Mr Shah initially told us that he didn’t know why she was bleeding so badly after the operation and indicated they were putting her on life support to give her heart a rest and to prevent it having to work too hard given what it had been through. He never mentioned putting it in upside down.
“It is shocking and can’t end here. We won’t allow it and we’ll continue to fight for justice for mum.”
Mrs Hynes had the operation to replace the aortic and mitral valves after suffering from shortness of breath. The operation was aimed at relieving her symptoms and extending her life, the inquest heard.
Mrs Hopper said her family had encouraged her to have the operation done, adding: “We told her that she had nothing to worry about and that she was going to the Freeman Hospital which was known for its transplants and heart surgery.
“Now we wish we’d never encouraged her as she’d still be with us now.”