Mr C - Non-inquest findings

87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chronic anthraco-silicotic lung disease

An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actually had a tissue valve; warfarin was for atrial fibrillation, not the valve. This error led to unnecessary bridging anticoagulation with heparin. The patient developed pulmonary haemorrhage, pneumonia, and respiratory failure post-procedure, dying 2 days after bronchoscopy. Autopsy confirmed haemorrhage as the primary cause. The critical lesson is the importance of accurate identification of prosthetic valve type and correct anticoagulation indication from existing records, as incorrect assumptions can introduce life-threatening bleeding risk during perioperative management.