Sheila Hynes
3 Jul 2017 · Coroner Karen Dilks · Newcastle Upon Tyne
The coroner's concerns
1. remounting valve on holder contrary to manufacturer's instructions
“During Mrs [name redacted] operation a direction was given to remount the Sorin Corbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer's instructions for use.”
2. lack of surgeon instruction on valve remounting
“The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.”
3. untrained scrub nurse instructed to remount valve
“Ascrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.”
Responses
No published response was found on judiciary.uk.