Inquest into the death of Ida ROMEO

59y · Female·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

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.