Inquest into the death of Audrey Yvette Carrick

83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic valve implantation)

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.