Police investigate heart deaths at NHS hospital

Used instead of open-heart surgery, the TAVI procedure involves inserting a new valve via a catheter through a blood vessel, often in the groin. The catheter guides the new valve to the heart and replaces the damaged one.

The procedure, which typically lasts between one and two hours, is usually carried out under local anaesthetic and is mainly performed on older patients.

Dorothy Readhead, from Driffield, went to Castle Hill to undergo a TAVI in summer 2020. The 87-year-old, an active member of her local church and a keen gardener, had been suffering bouts of breathlessness which doctors had blamed on a heart condition.

Deemed not suitable for open-heart surgery, Mrs Readhead was keen to take up the option of the less-invasive procedure. "She thought it would give her a [better] quality of life," says her daughter, Christine Rymer.

But the operation went wrong.

The care Mrs Readhead received formed part of both RCP reviews carried out on behalf of the hospital trust.

Pre-op checks had indicated Mrs Readhead's left side was to be used for the TAVI, as her right side had some blockages because of calcified arteries.

The manufacturer of the TAVI device that was to be implanted had also written a technical report clearly stating that access via the patient's right artery was unsuitable.

On the day of the operation however, the TAVI medics went in through Mrs Readhead's right leg by mistake. Realising their error, they paused to consider their options but decided to continue - despite the procedure being an elective rather than an emergency operation.

They attempted to deploy the TAVI three times.

The repeated efforts resulted in a significant tear in Mrs Readhead's femoral artery, a major blood vessel. By now, she had been on the surgical table for six hours, lost five litres of blood, and had been awake throughout.

But this suggestion was initially rejected by the vascular surgeon who had been part of the TAVI team.

"These were recognised complications which were anticipated as of significant risk... The aim of the [forthcoming] meeting is to celebrate and reinforce what went well," he wrote in an email.

The head of the TAVI team, agreed, replying it was "an unfortunate but well recognised complication".

The hospital did, however, investigate Mrs Readhead's case as a serious incident. While it noted that her death, a week after the operation, provided areas for learning, "these would not have prevented the incident from occurring". It concluded the team had "worked collaboratively and well together".

This conclusion was shared with Mrs Readhead's family, with no mention of the TAVI manufacturer's warning or the failure to deploy the device on three attempts.

The review's findings included:

Former fisherman Brian Hunter, from Grimsby, was another of the 11 patients who died. He had faith in the NHS, say his family, although rarely visited a doctor.

He lived by the maxim that "a hot curry or a paracetamol" would cure all ailments - and "if that didn't work you, you just got on with it," according to his daughter, Tracy Fisher.

His diagnosis of a heart problem therefore, at the age of 83, shocked his four daughters. But they and Brian were reassured a TAVI procedure would soon allow him to resume his gardening and cooking his Sunday roasts.

However, there was "a lack of urgency" to treat him, according to the 2024 RCP review - and by the time he underwent the operation, in October 2021, he was "a high-risk case… with an increased risk of complication and little margin for error".

The TAVI team had made technical errors, concluded the review, failing to properly deploy the device which then wrongly allowed blood to leak back into the heart.

Mr Hunter didn't survive the operation - the Royal College graded his care as "very poor". His daughters - just like Dorothy Readhead's family - had no idea what had happened during his operation until we showed them the report.

"We were led to believe that dad had a heart attack on the table and unfortunately passed away," said Mrs Fisher. "To find out three years down the line that what your father actually passed from wasn't the truth is torturous.

"I feel angry as well, and so does the rest of the family, that [the hospital] just outrageously lied. At no point do any of us find it acceptable. It's just not."