Inquest into the death of Audrey Yvette Carrick
Deceased
Audrey Yvette Carrick
Demographics
83y, female
Date of death
2019-01-22
Finding date
2024-12-06
Cause of death
Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic valve implantation)
AI-generated summary
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons centre on communication failures: an electrophysiologist's ambiguous note about pacemaker indication was misinterpreted by junior staff, and two concerning ECGs taken on discharge day were not escalated to senior clinicians. While anticoagulation pre-procedure was reasonable given bleeding risks, and discharge itself was not contraindicated despite residual heart failure symptoms, the failure to conduct planned electrophysiology review before discharge was a missed opportunity. The coroner found that a pacemaker would have offered only small survival benefit from pulmonary embolism but hospitalization for pacemaker insertion might have improved outcomes. Root causes were documentation clarity and communication gaps between consultants and registrars regarding ongoing review requirements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure of electrophysiologist to clearly document that pacemaker decision was provisional and required further review before discharge
- Failure to conduct planned electrophysiology review prior to discharge on 21 January 2019
- Possible failure to escalate concerning ECG findings from 21 January 2019 to senior clinicians
- Possible failure to communicate discharge plans to family regarding post-discharge monitoring
- Deep venous thrombosis likely developing post-TAVI procedure in setting of immobility and cardiac procedure
- Uncertainty regarding whether both ECGs taken on 21 January were reviewed by discharge clinician
Coroner's recommendations
- No formal recommendations issued; instead, the coroner encouraged staff involved to reflect on clinical practices. Dr D. has already implemented improvements including clearer documentation, enhanced registrar follow-up processes, and increased ECG interpretation education.
- Implementation of electronic Medical Record (ieMR) system at TPCH (scheduled for 2027) is expected to improve legibility, accessibility, and timely communication of clinical information between team members.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —