A mum who was diagnosed with a heart problem after feeling breathless died days after long-awaited surgery to fix the problem. Carlene Kershaw's operation was delayed on several occasions before finally taking place in June 2021.
The outcome of the procedure on the 40-year-old appeared positive at first but her condition quickly deteriorated. At an inquest on Wednesday, coroner Lydia Brown said the 40-year-old's death was an “awful outcome” after a number of complications arose following the four hour surgery.
Carlene, who had worked as a probation officer for the majority of her career, had first reported breathlessness in August 2019 and later began suffering vomiting, headaches and a tight chest. She would not undergo heart surgery until nearly two years later.
Speaking to MyLondon, her brother Mark Coffey said that his outgoing sister, from Hemel Hempstead, "didn't expect to die" and had been joking with her mum ahead of the surgery. He said she had just bought a house in Liverpool with a plan to start a new life.
He said: "It’s unbelievably awful and she just didn’t deserve that and neither did her children. Now they don’t have their mum, there’s been huge disruptions around loads of stuff, it’s been terrible."
The inquest heard that after her initial appointment in August, Carlene returned two months later to the outpatient clinic at Watford Hospital where it was established that there was a leakage of a heart valve. The matter was referred to a multi-disciplinary meeting and as she did not have severe valve disease, there were discussions about performing a TOE procedure.
This would be an echocardiogram through a telescope that would have been placed down Carlene’s oesophagus to look at her heart chambers. However, due to having difficulty swallowing, she became “restless and agitated” and the attempt was aborted.
It was agreed that a follow up appointment would take place in the New Year, but when giving evidence, consultant cardiologist Dr Niall Keenan said: “None of us knew in October 2019 that we were about to embark on the Covid-19 pandemic."
The hospital cancelled all operations and procedures as the cardiology team were re-deployed to help treat patients suffering with coronavirus. He told the inquest at West London Coroners Court that it had been “very challenging” to organise the echocardiogram during this period for Carlene.
After months of delays, she requested a transfer to Hammersmith Hospital to be under the care of Dr Bellamy, as her case was increasingly “sidelined” due to the ongoing pandemic. She now had "severe mitral valve regurgitation" and needed surgical intervention, the coroner said.
Giving evidence, Professor Punjabi, a consultant cardiothoracic surgeon, said that he had carried out a face-to-face meeting with Carlee, to explain the risks of the operation. According to UK statistics from all age ranges, there is a one in 20 chance of death occurring, but Carlene’s family said that she had been given “many reassurances” that the operation was routine procedure.
“Surgery was the only real option for Carlene, and if it wasn’t carried out fairly promptly, she was at risk of further deterioration,” Ms Brown continued. After arriving at the hospital for the operation on June 3, 2021, she was taken down to the theatre, only to be told at the last minute that there were no beds available and she was made to wait four days, an experience her brother said was "traumatic".
The four hour procedure eventually took place on June 7, and was initially believed to have been successful. Professor Punjabi said that she was “stable and steady” afterwards, and all signs had pointed to an “excellent operation” which meant that she was extubated that very same evening.
However, overnight her position deteriorated and she was intubated, reviewed constantly by the intensive care unit and was observed to be having breathing difficulties. Over the following days, she needed support with her blood pressure, antibiotics and underwent a “severe deterioration” on June 11.
Investigations showed that she had newly developed a coronary clot, which had to be surgically removed. Following that emergency procedure, resuscitation efforts were tragically unsuccessful and she was pronounced dead.
Her brother said: "She had every possible scenario thrown at her, bearing in mind she was four foot 10, she was a small lady and to fight through all that. She actually spoke to my mum quite quickly after the operation but very, very briefly and never came round again.
"I mean it’s been horrendous, when she walked into the hospital, she joked with my mum not to be so morbid about not coming back, and she never did. It’s been unbelievably traumatic for us."
Carlene's mother Sandra told the inquest that she had been inaccurately informed that her daughter had undergone a 10 hour surgical procedure and that she had been left “really shocked” at the swelling caused by Carlene’s condition. Professor Punjabi told the inquest that she had been “constantly monitored”, and any signs of sepsis or the blood clot would have been noticed immediately had it happened sooner.
Ms Brown said: “It was a combination of events that really conspired against her to take her life.” A post-mortem examination gave her cause of death as 1a) Myocardial infarction, 1b) Coronary thrombosis in connection with mechanical double valve replacements and left atrial appendage closure on 07/06/2021 and 1c) Congenital mitral valve anomaly.
Mum was 'kind, loving person'
In a statement read aloud by the coroner, her family said: “Carlene was a very caring, loving person and parent who put her children first, a daughter and a son. Carlene was a much-loved daughter, sister and auntie, she was one of four siblings to her mum Sandra. She was a highly-regarded probation officer, working in the probation service with high-risk offenders, trying to rehabilitate them.
"She worked in this area for her entire career - she always tried to see the good in people which made this occupation a perfect match for her. She graduated from university with two degrees, she was intelligent, sensitive and thoughtful. She was a strong, independent woman who loved life, spending time with her family and friends.
“She was a sociable, outgoing person who could make you laugh or cheer you up if you were having a bad day. She’d been invited to become a school governor at her children’s school, such was the respect she commanded in her local community. She enjoyed travelling and went to Camp America along the years, later taking her younger sister, providing camp support for underprivileged children.”
They continued: “Carlene was desperate to regain her active lifestyle and felt she was not being treated seriously by her GP and the NHS in trying to outline what she was experiencing physically in the two years run-up to what was a constantly delayed operation. Carlene was rarely unwell, nor was she what you’d describe as a sickly type person, she lived a full life, ate well, drank a glass of wine and generally took care of her physical wellbeing, making the leaking heart valve incredibly frustrating.
“She was a good judge of character and would place her trust in people. She wasn’t the type of person to shy away from what was needed if it was for the greater good. She was nervous about the operation and told us that she’d been offered many reassurances that the procedure was routine, and with her age and general health, she’d be back to her normal self in no time. She was very much looking forward to this.
Carlene, who had been due to move to Liverpool with her two children, was remembered fondly by friends and family in a GoFundMe online fundraiser that has been organised in her memory. Described by one as an “amazing friend” and a “diligent mum”, the page aims to provide her children with funds to follow in Carlene’s footsteps by travelling the world.
Closing the inquest, Ms Brown said: “It is difficult to give a short form conclusion such as natural causes, this is not a natural cause death, it is sadly provoked by that surgical procedure of course that was completely unwanted. This is not an accidental death, there is nothing accidental in the planning or the technical competence of that procedure.
“So I will return a conclusion, which is known as a short narrative conclusion to try and capture those elements. That this death was due to recognised complications of necessary surgical interventions."
Donations to Carlene's family can be made HERE.
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