Opportunities were missed to rectify an operation in which a heart valve was inserted the wrong way round on a 72-year-old great-grandmother who later died, a coroner has ruled.
Sheila Hynes could not recover from the acute heart damage that happened during what should have been a routine operation at the Freeman Hospital, Newcastle, led by surgeon Asif Shah.
She had undergone replacement of the mitral and aortic valves in March 2015, two months after he became a consultant cardiac surgeon, when the stitching chord snapped at a crucial moment.
Mr Shah had to then remove the mechanical aortic valve and he handed it to a scrub nurse ready to be reinserted.
The inquest heard she placed it on its mounting, ready to re-placed in the patient, and it was inverted on its holder.
Mr Shah then inserted the valve the wrong way round, and it was only later in the operation, when senior colleagues had been brought in, that this was realised.
On the third day of an inquest, coroner Karen Dilks gave a narrative verdict in which she said:
"Opportunities were missed to identify and rectify the position of the valve, causing Mrs Hynes acute heart damage from which she could not recover." Mrs Hynes had rheumatic heart disease, a progressive condition which caused her shortness of breath.
The operation, which she was told held a 6% mortality rate, was intended to improve the quality of her life and extend it.
The coroner said there were only four other cases of valves being inserted the wrong way world wide, describing what happened to Mrs Hynes as a "tragedy".
She will write to the health trust and to the regulatory body with a view to speeding up a redesign of the valve mounting which would prevent it being held in an inverted position.