Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary artery disease and left ventricular hypertrophy

A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-operatively. Although her Modified Early Warning Score indicated need for escalation, MET calls were not consistently activated despite meeting criteria at multiple time points. She suffered cardiac arrest approximately 15 hours post-operatively. Investigation revealed potential delays in defibrillation and inadequate familiarity of nursing staff with resuscitation equipment. Key clinical lessons: pre-operative cardiac assessment should have been more thorough given ECG abnormalities and murmur; post-operative hypotension required earlier recognition of potential adrenal insufficiency from long-term steroids; MET call criteria must be documented when overridden; resuscitation teams require regular training in advanced life support and equipment.