Findings of Inquest into the death of Audrey Yvette Carrick

Audrey Yvette Carrick, an 83-year-old woman, from Taigum QLD died on 22 January 2019 from pulmonary thromboembolism (namely, a clot) due to or as a consequence of, aortic stenosis.  Only 8 days before, she had undergone a Transcatheter Aortic Valve Implantation (TAVI) procedure at The Prince Charles Hospital (TCPH) in Brisbane.

A TAVI is a minimally invasive procedure used to treat severe aortic stenosis, a condition in which the aortic valve becomes narrowed, restricting blood flow from the heart to the rest of the body. This can cause shortness of breath, chest pain and fatigue. Unlike traditional open-heart surgery, TAVI does not require a large incision or stopping the heart, making it suitable for patients who are at high risk for conventional surgery. ​

In Mrs. Carrick’s case, her advanced age, several other heart issues, hypertension, and gastrointestinal bleeding, all put her at higher risk for conventional surgery.  Without treatment, Mrs Carrick’s life expectancy was expected to be limited.  As it turned out, she died the day after her discharge from TCPH, so her death was reported to the coroner.

The coroner undertook a full Inquest to determine:

1. Whether Mrs Carrick’s pre and post procedure heart failure was recognised and treated appropriately.
2. Whether a failure to implant a pacemaker contributed to Mrs Carrick’s death.
3. Whether the decision to discharge Mrs Carrick on 21 January 2019 was appropriate.
4. Whether any further recommendations could be made to prevent future deaths in similar circumstances.

The coroner heard evidence from two cardiology experts; Dr. Kenneth Hossack, who was critical of aspects of Mrs Carrick’s care, although he had never performed a TAVI and had limited experience of hospital care in a public setting, and Dr. Anthony Camuglia, who found Mrs Carrick’s care to be of high quality. ​ As an expert in interventional cardiology, having performed over 1000 TAVI procedures, and with considerable experience of public health, the coroner gave more weight to Dr Camuglia’s opinion.

Since the coroner found that Mrs Carrick’s clot developed after her procedure, it followed that it was not necessary to have prescribed pre-surgical anticoagulant medication and that the doses given during the procedure and from 17 January 2019 were sufficient to minimise her risk of clotting.

The coroner found that it was reasonable not to undertake several other treatment options suggested by Dr Hossack, such as diuretic medication prior to the procedure, and percutaneous drainage of fluid around the heart after the procedure.  She did find that Mrs Carrick would have been a suitable candidate for the insertion of a pacemaker, but that would not have prevented her death.

Mrs Carrick appeared to have improved and was ‘desperate to go home’ so discharge on 21 January 2019 was deemed appropriate.

The coroner made some general recommendations focused on improving communication and documentation practices, primarily because the hospital’s records are largely paper based however, she noted an integrated electronic medical record (ieMR) system is due to be rolled out by Queensland Health in 2027.  She also stated “In memory of Mrs Carrick, a collage of photographs was displayed whilst Mrs Carrick’s daughter read out a family statement on the last day of the Inquest. Suffice to say that the statement was heartfelt and sincere. It is clear that the loss of Mrs Carrick has had a devastating impact on those left behind”.