Death by hypertension. not on bp medication

No one asked for autopsy. They did one because of age and circumstances of dying sudden. We rang the coroner to find out what cause of death was. She said natural causes being hypertensive heart disease. When we said hows that? She said that we would of known from the bp medication hed of been taking. She 'assumed' hed be on them. But he has never been prescribed them as we have his medical records. Twice the have 'considered it' but never had he had any. Because we were shocked and confused as to why he wasnt on bp meds. The coroner told us to request a full autopsy report. We have that now. In the report, the coroner states it as hypertension and refers to gp records saying 'elevated bp readings.

Sudden death is a good enough reason. Often if a person has been under medical care up to the time of death they do not want to do one as they think they know the cause of death.

My brother in law had been in hospital for over six months and the hospital issued a death certificate where his family disagreed with the cause of death. They had to insist and persevere to get an autopsy that showed the cause on the death certificate to be wrong and the coroner criticising the hospital. 

Do you fully understand the autopsy report and his medical records or is a lot of it confusing?

It appears very vague and as I mentioned earlier, 'hypertensive heart disease' covers a group of disorders and the autopsy should have covered which one of those it was.

Please do come back when you have had the meeting with the GP and let us know what he/she said.

We dont really undetstand it to be fair

It reads

1a hypertensive heart disease.

Death due to natural causes.

Comment

An enlarged heart places a aignificant nutritional burden on the heart to perfuse its muscle. Imvariably small areas of scarring are present at microscopic level due to undernourishment which can act as a subtrate for potentially fatal arrhythmia.

Two parts of the report are as follows

Respiraroty system

There were no pleural effusions, adhesions or pleural plaques. The pharynx and trachea and main air passages were unremarkable. The right and left lungs were terminally congested but showed no indication of any pulmonary embolism, infection or neoplasia.

Cardiovascular system.

The great veins were unremarkable. The aorta contained a moderate quantity of asherosclerosis in its abdominal portion. The heart was considerably enlarged and overweight. (Approximately double the expected size) there was concentric hypertrophy of the left ventricle which measured 20mm in thickness (normal up to 14mm) the cardiac valves appeared normal and the coronary arteries showed only mild coronary artery disease. There was no evidence of any coronary artery thrombosis or indication of an acute myocardial infarct. The most likely cause of the left ventricular hypertrophy is hypertension in the absence of any valvular disease. In this context i note the general practitioners records which showed elevated blood pressure readings.

Hi James,

Thanks for posting the extracts from the coroner's report.

I'm not saying this is what it was, but the para about the enlarged heart fits perfectly with PAH, particularly when taken together with the comment under "respiratory system" that both lungs were terminally congested. This congestion is what would have caused back-pressure on the heart, causing it to enlarge massively. General arterial hypertension would have had a similar effect, but wouldn't have been necessary to produce this effect in the presence of severe congestion in the lungs.

The rest of the report is just saying that your father hadn't had a heart attack (myocardial infarct) although there were signs that the blood supply to his heart muscle had been reduced due to the enlargement, his heart valves were normal, there was a moderate degree of hardening of the aorta (the body's main artery) - though this wouldn't really be abnormal in a 67-year-old - and there were no signs of pneumonia or malignancy in his lungs.

I'm not sure how up-to-date the coroner is in his views on blood pressure. Certainly, 10 years or so ago, when 120/80 was the only acceptable BP in any circumstances, your father's BP readings would have been viewed as elevated, but only moderately so even then. These days - as already discussed - most doctors would view these levels as only very mildly elevated or even normal in a man of 67, though some still adhere to the old rules. It's possible that the coroner was of this school of thought.

There's really nothing in your father's BP levels, as listed by yourself, that would have caused severe alarm, even 10 years ago. Even the final, and highest, reading of 155/90 is only at the top limit of Stage 1 hypertension. Given that the readings taken shortly before that were in the range of normal to pre-hypertension, many doctors these days would prefer to adopt a stance of "watchful waiting".

Your father's GP may also have felt that adding in extra medication, with its inevitable side-effects, would have increased your father's distress. I don't think you've mentioned anywhere whether or not he had told the family that he felt your father was approaching the end. If he thought this was the case, this might also have discouraged him from adding to the load on your father's failing systems by prescribing further medication.

I sympathise completely with your mother's concern but in my (slightly informed) opinion, the failure to prescribe BP medication doesn't indicate neglect or malpractice of any kind. I suspect the coroner's remark about your father being on BP medication might just have been an ill-considered throw-away which has, quite understandably, been taken out of context.

Further to my most recent post on your extracts from the coroner's report, there are a couple of points I should have mentioned. (I'm on the night shift right now and it's a very quiet night so I have time on my hands!)

You don't say whether the coroner mentioned whether he'd seen your father's BP readings in the run-up to his death. You also don't say whether these came from his official medical records or from home readings, which might or might not be accurate.

I've been going through these readings. If correct, the readings for the last year of your father's life average out at 146/86. This is more or less normal, and certainly nowhere near the levels required to produce massive enlargement of the heart. To produce the levels of enlargement described in the coroner's report I'd expect BP levels of something like 200/140 over a period of 10 years!

I'm sorry but there's something wrong with this story.

'I'm sorry but there's something wrong with this story.'

That is what I have been vaguely hinting at, but my reluctance to voice it clearly, stems from not wishing to worry or upset the OP.

There is another hypertension that is the cause of PAH, portal hypertension.

Portal hypertension - yes indeed, that was what I was referring to in discussing the excessive alcohol comsumption. Nice to know there's another night owl in here!

Whilst I am very happy that we have the NHS and dislike the people who try to privatise it, their lack of being honest and open with people (including me) is somewhat annoying.

I have portal hypertension and I believe I take carvedilol for it. I say believe, because no one has ever explained the eight medications a day I take, to me.

But carvedilol is also taken for CHF and I believe that I also suffer from that. Bit by bit, I am slowly getting answers to all my conditions, but it is like pulling hen's teeth.

Another reason that I wonder about CHF, is that when I was emergency admitted to hospital, I was given an ECG, which had; 'consider anteroseptal infarct'.

Right, enough night owl for me, I need some sleep.

Oh Mr. GBH - I thought you were more assertive than that! Though as an NHS veteran from way back when, I know how they play their cards close to their chest. Not the ideal system - we do it better in continental Europe, though one still has to apply a bit of muscle from time to time.

Re the night-owl stuff - me too. My oppo has just relieved me. Crashing out now. Sweet dreams!

Hi again.

Basically my father had a cyst removed on his thumb a few years ago. About feb march this year, it came back and it looked really painful. my mother forced him to go a.e on the 10-03-17. on the 12-03-17 at about 01:30 in the morning whilst he was alseep, he awoke my mother with some weird type noise, almost ike letting the air out of a ballon. well, i got to the house about 2:15. they pronounced him dead at 03:17.

Me and my mother thought he had sespsis from the poorly thumb. We rang the coroner a week after his death and she told us he had died from natural causes being hypertension.

Since then, my mother has been concerned as he was never on meds of bp. So we contacted the g.p and paid £50 for all his medical records from the gp.  Going through the records, all the bp reading i have given are the only ones on his record. Theres mayb one from like 1968 that is around 120-78.

What seems wrong with the story? I know last year they found the b12 deficiency, he was on a few meds. one was an injection.

 

Thank you lily for your information,

I think it's just a case of my mother wanting answers. We are in process of seeing the g.p and hopefully they can give us some info.

I do believe what you were saying about the type of hypertension 'that doesnt get picked up by a bp machine' is the kind that caused his death.

An answer like that is good enough for me. he was always on the weights on at home and was a builder and do heavy labour, his latter years he didnt really do too much other than walking with my mother to shops and so forth. he was always very slim and mayb he lasted longer than he should of with all that taken in to account? of course because he has smoked since about 13! all this didnt help. I remember him swimming two lenghs under water the once. Abit of a weird cookie for someone he didnt really do alot of heavy cardio exercise.

here is the full report, i just took his name out

BIRMINGHAM AND SOLIHULL DISTRICTS

CORONER'S COURT

Pathologist: Dr. S. E. Trotter

Report on the Autopsy of the Body of:

Age 67 Performed at: The Central Mortuary, Birmingham

At: on the 20 March 2017

ACTING ON THE INSTRUCTIONS OF H.M. CORONER FOR BIRMINGHAM & SOLIHULL DISTRICTS, BY VIRTUE OF PART 3 OF CORONERS (INVESTIGATIONS) REGULATIONS 2013.

Date and Time of Death: 12 March 2017 at 03.17

Place of Death: City Hospital, Birmingham

Other Doctors present at Autopsy: None

CIRCUMSTANCES OF DEATH

The deceased arrested at home and paramedics initiated cardiopulmonary resuscitation, despite return of circulation he arrested again and attempts at revival were discontinued.

POST MORTEM

Organ Weights Right Lung

 

 

975g

Left Lung

1141g

Heart

588g

Liver

1633g

Right Kidney

250g

Left Kidney

250g

Spleen

Brain

91g

 

 

 

 

 EXTERNAL EXAMINATION

A male subject showing no signs of neglect or injury. Weight 69.0kg, Height 175cm, BMI = 22.5

 

INTERNAL EXAMINATION

Respiratory System

There were no pleural effusions, adhesions or pleural plaques. The pharynx and trachea and main air passages were unremarkable. The right and left lungs were terminally congested but showed no indication of any pulmonary embolism, infection or neoplasia.

 

 

Page 2 of 2

Cardiovascular System The great veins were unremarkable. The aorta contained a moderate quantity of atherosclerosis in its abdominal portion. The heart was considerably enlarged and overweight (approximately double the expected size). There was concentric hypertrophy of the left ventricle which measured 20 mm in thickness (normal up to 14 mm). The cardiac valves appeared normal and the coronary arteries showed only mild coronary artery disease. There was no evidence of any coronary artery thrombosis or indication of an acute myocardial infarct. The most likely cause of the left ventricular hypertrophy is hypertension in the absence of any valvular disease. In this context I note the general practitioner’s records which showed elevated blood pressure readings.

 

Gastrointestinal System The mouth, tongue and oesophagus were unremarkable. The stomach and small intestines appeared normal. The large intestinal was markedly dilated but no obstructive mass was seen. The liver was congested but had a smooth surface. There was no focal lesion on serial slicing and both the biliary and pancreatic systems were unremarkable.

 

Urogenital System The right and left kidneys were of similar size. They showed no focal lesion on the cut surface but some age-related changes were noted. The capsules stripped with ease. The ureters externally were unremarkable and the bladder showed no abnormality.

 

 Endocrine System The adrenals and thyroid were unremarkable. The pituitary and parathyroids were not examined.

 

Reticuloendothelial System The spleen was terminally congested but had a firm pulp. There was no indication of any lymphadenopathy.

 

Central Nervous System There was no evidence of any cutaneous injury to the scalp and no palpable skull fracture was felt. In view of the findings elsewhere, the brain was not examined

 

 In my opinion the cause of death was: Ia Hypertensive Heart Disease Death due to natural causes Comment An enlarged heart places a significant nutritional burden on the heart to perfuse its muscle. Invariably small areas of scarring are present at microscopic level due to undernourishment which can act as a substrate for a potentially fatal arrhythmia. I note from the circumstances of death the deceased had been troubled with recurrent painful cysts on the hand. I can see no relevance of these cysts to the cause of death, particularly with such an enlarged heart.

p.s,

the copy and paste has put the 91g for the brain but it should be spleen

Hi James,

Now I understand a bit better. It must have been terribly distressing for your mother to wake and find your father dead beside her, and distressing too for you having to cope with all this.

All I meant by "something wrong with the story" was that it seemed a bit odd to me that the coroner would make that remark about BP medication. However, I don't think it's in any way sinister. I was also a bit puzzled about your insistence on going into all this, but now I understand perfectly of course.

Yes, his heart was very large, and so were his lungs. But then both could have been down to chronic lung congestion, which would in turn have caused back-pressure on the heart (i.e. PAH, as already discussed).

I was interested by another bit of information in your recent offering. Your father was clearly a pretty impressive athlete in his day, and I'm guessing his job as a builder would have served the same purpose as an athlete's regular training. Athletes often have markedly enlarged hearts. In their case it's not pathological, it's just the result of extra muscle being formed because of constant exercise - the same way they develop big arm or leg muscles. I'm guessing your father would have been a generally well-muscled individual before he became ill, so it would have been normal that his heart was large too.

However, if he'd stopped exercising a few years before his death, a lot of the extra heart muscle would have turned to fat, like his more visible muscles. Also, the description of his heart in the autopsy report fits with a reaction to some form of hypertension as well.

I doubt whether the thumb played any part in your father's death. You don't say whether or not he was ill (or more ill than usual) after his return from the hospital, but it doesn't sound from your description as if this was the case. Sepsis makes people very ill indeed - weak, breathless, high fever, poor colour etc., as well as feeling absolutely terrible - so I think your mother would have noticed a change like that in the day or so before his death.

I'm in no position to say, of course, but looking at this from the outside it sounds to me as if you're describing a man whose lungs had been wrecked by 50+ years of quite heavy smoking, and possibly by long-term exposure to dust or other irritants throughout his working life. You don't say how much he was drinking, and I wouldn't ask, but as RHGB has pointed out, he was on medication (including vit B12 injections) which could have been prescribed for alcohol-related pathologies. This may also have played its part in what sounds like a pattern of premature ageing of your father's organs.

I hope you can all find some degree of closure soon. I really understand what you're going through, and the understandable desire to help your distraught mother. My father died very suddenly of complications of lung cancer 30 years ago. In his case the cancer had infiltrated the wall of the aorta, and part of it had broken away and entered his circulation, causing a massive pulmonary embolism and instant death. He had worked in asbestos-laden air with no protection whatever throughout the 1960s (still legal in those days) so my mother inevitably made the connection. I did a lot of research for her - not so easy in pre-internet days - but I always knew his lifelong 50-a-day habit would have scuppered any case we attempted to bring. In the end, my mother decided not to proceed further, but it took her about six months to come to this conclusion. I think the desire to find answers was a necessary part of her grieving.

It sounds as if you're being a wonderful support to your mother. Don't forget to look after yourself too!

Thank you for your time in response. Sorry to hear of your loss too. The sudden loss hits us and its like it isnt real!

He drank everynight, for probably most of his life! whiskey was th emain one which he had ot cut down as his liver was getting bad.

But, as i told my mother, he didnt help himself with the smoking and drinking. And i did tell him this that he would have to stop as he got older. But obviosuly it was too late, but him dying sudden in his sleep better for him. 

Do you think the doctor would of known about if hed have long to live? I dont know. all this information has helped me so much, its answers alot. 

Thank you.

Also when me and my mother look back now, he was out of breath quite easy the last few years and also would pass out. he fallen down the stairs a few years ago, my mom blamed him being drunk! but he insisted he wasnt, he collopsed putting his shoe on last year. and there were times whilst out shopping with my mom that he would have to sit down alot as feeling faint. So all this now makes sense.

 

Well, I don't want to sound flip but the doctor clearly knew your dad had a dicky liver, and presumably knew he was still drinking, so I imagine he'd figured out that he was unlikely to get the royal telegram. However, survival rates in any condition are notoriously hard to estimate, even when death seems imminent, so I doubt whether he could have predicted that your dad would go when he did.

The other possibility is that he may have been brutally honest with your father about his prognosis, but that your father asked him not to tell your mother or you. This often happens in families and I think it's rather sad, because death can them come as a shock. That being said, it always comes as a shock anyway. My mum died in hospital at age 89, weighing only 34kg and in a terrible state - dementia, bedsores etc. - but it still came as a devastating shock.

I think you said you were going to talk to his doctor. If you do, this is one of the things you should bring up.

'This often happens in families and I think it's rather sad'

I think you would need to be in this position to understand it. Quite often other family members don't want to hear the news or even refuse to believe it, because the patient isn't showing many/any outwardly signs of illness.

I am assertive, but it is a battle of attrition. I am on the final stage, of sending a formal complaint to the chief excutive of the hospital.

I have been through three hospitals (original one, second one - sent to for neuro surgery and then the stroke rehab hospital) and two PALS (patient liaison services).

I always do everything by the book, go through any complaint services they have and say at length, that I am not really looking to complain, but just to be given an answer. I have left them nowehere to hide and taken all the emotion out of any communication.

I think it is a case of, partly they believe everyone is out to make a claim and partly that they have in inbuilt problem in admitting they might have got something wrong or not handled it as best they could.

I have actually been in this position, albeit at some distance. 50 years ago my aunt died of uterine cancer aged 51 a couple of weeks after going into hospital for what she'd told everyone was a minor op. She'd been pale and tired for a few months, but had insisted it was just the menopause. She'd remarried and had a second family late in life, so she left children aged 11 and 9 as well as her husband and her daughter from an earlier relationship. All were completely devastated. She only allowed her doctors to tell her husband the truth a few days before the end.

Nearly 20 years later, when my father had just received his own diagnosis of cancer, he told me that his sister had known the truth about her own illness all along, and that he was the only person she had confided in. She'd sworn him to silence and he'd honoured the promise for all that time. He said he still felt guilty about the pain he'd seen her children go through because of what they experienced as her sudden and unexpected death. He deeply regretted not having insisted she tell them the truth as soon as she got the diagnosis, so they could have said their goodbyes properly.

Sorry, to clarify, I meant, to be in the position of the person who is dying or who has a terminal illness.

I don't know if they still them have but at one time as in the case of our daughters death we went through the hospital procedures and then had a National Health Inquiry. There is a chairman and in our case two professors from different hospitals hear the evidence and make a decision.   

What exactly is it you're trying to find out? If that question isn't too personal, of course.

I take he did not consult his GP about those episodes as they would have certainly have been cause for invesigation.

On a simple level, what caused my stroke. But I think your question was probably seeking a more indepth answer.

The forum doesn't show which message of mine you were replying to.

The one about your being assertive but it being a battle of attrition. (Another bloody night shift - everyone seems to have gone AWOL!)

That's the thing about Continentals, always on a break. I'll give a more in depth answer tomorrow. The witching hour is here and I need to put my head down.

Yup - me too! Just handed over. Over and out.