Inquest into the death of Yaqin Han
Deceased
Yaqin Han
Demographics
69y, female
Date of death
2022-10-14
Finding date
2026-09-22
Cause of death
Aortic stenosis
AI-generated summary
Yaqin Han, a 69-year-old woman with aortic stenosis, died on 14 October 2022 during an exercise stress echocardiogram at QEII Hospital from a fatal cardiac arrhythmia provoked by the test. The coroner found that Dr V. failed to conduct direct clinical assessment of Mrs Han before ordering the repeat exercise stress echocardiogram, missing the opportunity to identify that she had developed symptomatic aortic stenosis—an absolute contraindication to the test. Although the test may have been defensible given ambiguity about severity, the failure to speak directly with the patient was a critical omission. Mrs Han's care was fragmented across six different cardiologists, compounded by COVID-19 disruptions and healthcare system redirection away from the specialist heart valve centre. Dr R. appropriately stopped the test when symptoms emerged, but by that point the fatal arrhythmia had already been triggered.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Fragmented care involving six different cardiologists and multiple cardiology registrars over the patient's 3-year clinical course
- Failure of Dr V. to conduct direct clinical assessment with Mrs Han before ordering the repeat exercise stress echocardiogram
- Failure to obtain current symptom status from the patient, who had not been reviewed by a cardiologist for nearly 12 months
- Reliance on outdated invasive pressure measurements from May 2021 coronary angiogram showing moderate stenosis
- Cancellation of planned in-person clinic review on 27 September 2022, replaced by chart review only without patient contact
- Ambiguity regarding severity of aortic stenosis due to discordance between invasive and non-invasive findings
- COVID-19 pandemic disruptions to continuity of clinical care and in-person consultations
- Healthcare service model redirecting advanced valvular heart disease patients from Princess Alexandra Hospital centre of excellence to QEII Hospital general cardiology service
Coroner's recommendations
- Metro South Health should reexamine its model of cardiac care to identify opportunities for its centre of heart valve excellence at Princess Alexandra Hospital to better support local cardiology services managing patients with advanced valvular heart disease
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