Coroner's Finding: Mackey, Lois Winifred

83y · Female·decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement in the setting of multifactorial chronic pulmonary hypertension

An 83-year-old woman died from decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement surgery. She had chronic pulmonary hypertension secondary to severe mitral regurgitation from mitral valve prolapse. The coroner investigated whether earlier diagnosis by her GP would have prevented her death. Review concluded the GP's management was reasonable—he was anchored to a diagnosis of recurrent chest infections/pneumonia, cardiac examination was not routinely indicated, and time pressures were significant. Observational data suggests earlier surgery would have produced better outcomes, but no criticism of the GP was warranted. The surgical team appropriately recognized risks (predicted mortality 7%) and performed necessary surgery competently.