A beloved mum died only days after a heart surgery that she had waited years for.
Carlene Kershaw had spent two years waiting for a crucial operation to help with a leaking heart valve before she finally had it.
But in the immediate aftermath the 40-year-old from Hemel Hempstead tragically died after a blood clot formed.
After her surgery was delayed on several occasions before it finally took place in 2021, she said she felt she was “not taken seriously” by her GP or the NHS.
An inquest heard how her untimely death was the “awful outcome” of a number of complications arising after the four hour surgery she had at Hammersmith Hospital last year.
Coroner Lydia Brown led the inquest into the death.
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, and despite the operation appearing positive at first, her condition quickly deteriorated.
Speaking to MyLondon , her brother Mark Coffey said that his sister "didn't expect to die" and had been joking with her mum ahead of the surgery.
He said: "She had just bought this house in Liverpool to start a new life, she never got to live in that house.
“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 court heard that after her initial appointment in August, she returned two months later to the outpatient clinic at Watford Hospital where it was established that there was a leakage of a heart valve.
“Following investigations, it was identified in October that she had moderate mitral valve regurgitations and mild aortic valve regurgitation, these were established to be congenital difficulties that hadn’t previously given her any symptoms,” Ms Brown summarised.
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, Carlene 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.
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.
Mark told MyLondon: "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 mum 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.”
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."
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."
If you wish to donate to Carlene's family, the GoFundMe link is here .
