Coronial
NSWhospital

Inquest into the death of Ida ROMEO

Deceased

Ida Romeo

Demographics

59y, female

Date of death

2012-07-05

Finding date

2016-04-08

Cause of death

acute cardiogenic shock, with acute mechanical obstruction of a remote mechanical aortic valve replacement and intraprocedural displacement of a cardiac catheterisation wire across the valve as antecedent causes

AI-generated summary

Ida Romeo, 59, died during cardiac catheterisation at Liverpool Hospital when a pressure wire became trapped in her mechanical aortic valve. She had consented to a right heart study to investigate suspected constrictive pericarditis, but not to the subsequent pressure wire insertion across her valve. The decision to attempt this procedure was made after initial test results were inconclusive and Ida was already sedated. Critically, no consent was sought for this undisclosed procedure. The trapped wire caused acute cardiogenic shock with cardiac arrest. While the technical skill of clinicians was not questioned, the case highlights failures in informed consent, failure to discuss alternatives with a conscious patient, and lack of planning for uncommon procedures. Key learning: obtain consent before sedation, discuss novel/high-risk procedures thoroughly with patients, implement safety checklists matching procedures to documented consent, and establish approval processes for new interventional procedures.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologyintensive carecardiothoracic surgery

Error types

consentcommunicationproceduralsystem

Drugs involved

fentanylmidazolamsalineadrenaline

Clinical conditions

constrictive pericarditis (suspected)restrictive cardiomyopathy (differential diagnosis)aortic stenosismechanical aortic valve replacementcardiac arrestcardiogenic shockpulmonary haemorrhage

Procedures

cardiac catheterisationcoronary angiographyright heart catheterisationfluid loadingpressure wire insertion across mechanical aortic valvecardiopulmonary resuscitationendotracheal intubationtransoesophageal echocardiography

Contributing factors

  • pressure wire became trapped in mechanical aortic valve
  • absence of informed consent for pressure wire procedure
  • procedure performed while patient sedated
  • decision to perform pressure wire insertion without discussion with conscious patient
  • no pre-procedure planning or approval process for uncommon procedure
  • no consultation with experienced colleagues regarding novel procedure

Coroner's recommendations

  1. To the Director, Medical Services, Liverpool Hospital: Consideration be given to having an appropriately qualified medical practitioner prepare a summary of, or article about, Ida Romeo's case for submission to an appropriate medical journal and/or circulation to other cardiology departments in NSW hospitals, contingent upon Mrs Romeo's name not being published
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