Jenna Evans’ family believe doctors missed clear warning signs before her sudden death in July 2024
Ms Evans had a mechanical valve fitted in 2017(Image: Family of Jenna Evans)
A mum-of-four died from a rare heart infection just days after she was admitted into hospital. Jenna Marie Evans, 40, died from endocarditis seven years after she had a major heart operation, her family believe clear warning signs were missed.
Ms Evans’ mother was shocked her daughter had been sent home from hospital a month before her death and the day after she was told she was too unwell to be discharged. She added that they had no idea her quite how serious her condition was.
The serious infection which led to her death was so rare, her doctor had only seen it once before in his 21 year medical career.
Ms Evans was born in Aberdare in 1984. She grew up with her three siblings in an extremely tight-knit family. Her family described her as being sociable and someone who enjoyed spending time with family and friends, and holidays, days out and concerts. They said she was a “fantastic mum”.
The mum-of-four, who lived in Bryntirion, Mountain Ash, worked as a care assistant for adults with disabilities and her family said her death had left “a massive hole in all our lives”. For the biggest stories in Wales first, sign up to our daily newsletter here.
Jenna Evans’ family had no idea how serious her condition was (Image: Family of Jenna Evans)
During her inquest, Pontypridd Coroners Court heard how in 2017, when Ms Evans was in her early thirties, she was preparing for an unrelated procedure and doctors picked up that she had aortic stenosis.
The serious condition meant one of her heart valves wasn’t working properly and the only solution was to have major heart surgery which involved her having a mechanical valve fitted at the University Hospital of Wales in Cardiff.
The inquest heard from Dr Govardanm Navaratnam, Ms Evans’ consultant cardiologist at Prince Charles Hospital, that the surgery always means there is a risk of endocarditis but this is most common in the immediate aftermath. Endocarditis is a rare infection of the inner lining of the heart which can prove fatal.
On May 5, 2024, she sent messages to a family member complaining she couldn’t catch her breath and saying how she thought she might die.
After feeling increasingly unwell and struggling with breathlessness, Ms Evans was admitted into hospital on May 30, 2024 and treated for Covid-19 and told she had an infection. While she was there she had bloods and scans done and on June 2 a doctor told her her infection was “really bad”, she was really unwell and he said he wanted her to stay in.
However, on June 3 a different doctor sent her home.
Jenna Evan’s family said her death is “still so painful”(Image: Family of Jenna Evans)
Following her release from hospital, Ms Evans continued to feel unwell and on July 17 she told family that she still didn’t have any answers and that the doctors didn’t know what was going on with her.
Six weeks after her hospital stay she was readmitted to hospital on July 21 with symptoms including abdominal pain, muscle pain, pelvic pain, blood in her urine, breathlessness and rapid loss of weight. She was placed on fluids and pain killers.
On July 24 she had been referred to the cardiology ward after other doctors ruled out several other causes of her infection, including different cancers and lymphomas. At around 5pm she started on antibiotics.
During the day she sent a message to her husband asking him to bring in some items from home. Him and one of their children arrived at Prince Charles Hospital to find her lying on her back, looking grey and struggling to catch her breath. Her child asked staff to come three times.
Unfortunately, Ms Evans’ condition rapidly deteriorated and at around 7.30pm she went into cardiac arrest, doctors worked on her for 45 minutes but she sadly died the same evening.
The inquest heard how Ms Evans’ mother felt her daughter had been wrongly discharged when she was in hospital in June because she couldn’t understand why she’d been sent home the day after she was told she was very unwell and therefore couldn’t go home. She also said her daughter had been asking for help for around 20 minutes when she went into cardiac arrest.
Her cause of death was given as aortic stenosis, which led to infected endocarditis which caused her to go into cardiac arrest.
Ms Evans’ family feel like doctors missed key warning signs leading up to her death(Image: Family of Jenna Evans)
The inquest heard evidence from Dr Govardanm Navaratnam, a consultant cardiologist at Prince Charles Hospital who first met Ms Evans in 2017. He said how at the time the care assistant had taken the news that she needed major heart surgery “very well”, adding that it showed her strength of character.
He said that hadn’t expected her sudden death and in retrospect agreed with her earlier doctors that her June discharge had been a safe move despite differing views between doctors and didn’t believe it was related to her death.
He told the court that with valve conditions sudden deterioration is something they are concerned about but stressed how the operation had enabled her to live a healthy life for a number of years. He said that in Ms Evans’ case she had a particular bug which worked quickly and caused destruction to a major organ that could not be turned around in time.
Dr Navaratnam continued: “I don’t think there was anything in her herself that would have caused this. She would not have survived without the operation but she succumbed to a horrible condition that rapidly deteriorated.”
Dr Chugtai, a consultant at Prince Charles Hospital who was involved in her care during her final hospital admission, also gave evidence. He explained how they had to rule out a number of reasons why she had an infection and that since he qualified as a doctor in 2003, this was only his second time ever seeing a case of endocarditis.
He added: “It was very very surprising, I wasn’t expecting that to happen at all.”
Coroner Rachel Knight concluded that Ms Evans died by natural causes(Image: Family of Jenna Evans)
When concluding the inquest, Coroner Rachel Knight said she had heard evidence that endocarditis could be developed at any point after the surgery, although most common shortly after.
She said: “I’ve heard extensive evidence that it is challenging to diagnose this infection. She likely had unrelated symptoms in May 2024. It’s more likely than not that in the four to six weeks between she was developing that endocarditis. Doctors had to rule out a lot of very serious causes in the first instance.”
She said that once they ruled out other causes it was right that she was transferred to cardiology and the treatment for this condition would be antibiotics and identification of the relevant bug to treat it. Coroner Knight added that this was not a good diagnosis and would’ve meant a “prolonged hospital stay”.
She concluded: “I can’t find any evidence that any human act would have changed the tragic death.”
Coroner Knight ruled Ms Evans had died by natural causes.
Jenna’s mum Susanne Roberts spoke to WalesOnline following the conclusion of her daughter’s inquest. She said: “We are absolutely heartbroken as a family, our lives will never be the same without her, we’re grieving a family member; a mum dad, husband, sister, brother and daughter. We just feel like the warning signs were there, we didn’t feel like it was fatal but from April it was ongoing her not feeling well.
“We feel let down by the GP all the way up that not enough was done. We keep wishing we’d gone private thinking that might have made a difference but we didn’t know how serious it was and it sounds like no one realised how serious it was, not even the doctors.
“We feel like she had this bug for longer and the damage was done more slowly. We had no idea that it was life-threatening so it was a huge huge shock. Her children are still young and in school, it’s heart-breaking. Even after this time it’s still so painful.”