Source · Prevention of Future Deaths

David Jones

Ref: 2025-0514 Date: 14 Oct 2025 Coroner: Nathanael Hartley Area: Nottingham and Nottinghamshire Responses identified: 1 / 1 View PDF

The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.

Date 14 Oct 2025

56-day deadline 9 Dec 2025 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

This is not the first inquest involving the Trust where there have been concerns about an undiagnosed aortic dissection. I am personally aware of another recent inquest in which evidence was provided to assure the coroner that relevant learning has been disseminated across the appropriate departments at the Trust, and processes amended to try to prevent recurrence. I am also aware of evidence given to my coroner colleagues about the Trust’s educational programme, particularly for the emergency department team. 1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department, despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments.
2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change. I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow.

Responses

1 respondent

Nottingham University Hospitals NHS Trust NHS / Health Body

9 Dec 2025 PDF

Action Planned

The Trust is undertaking an Acute Aortic Dissection Improvement project, involving multiple teams and collaboration with the East Midlands Aortic Network, to improve early detection of the condition. (AI summary)

View full response

Dear Miss Casey Please find enclosed Nottingham University Hospitals NHS Trust’s (NUH) response to the Regulation 28 Prevention of Future Deaths Notice issued by Assistant Coroner, Nathaniel Hartley, on 2 September 2025, following inquest into the death of the late Mr David Charles Noel Jones. This response describes a program of work at NUH with workstreams supporting the improvement of early diagnosis of Acute Aortic Dissection. Here we summarise the completed, ongoing and planned future work within NUH to improve the early detection of Acute Aortic Dissection; the Acute Aortic Dissection Improvement project. This work will be undertaken by an Acute Aortic Dissection Improvement Group led by the Cardiac Surgery team, with support from colleagues in the Emergency Department, Acute Medicine, Stroke, Radiology, Patient Safety team and the Medical Director’s Office, and involves other teams such as Stroke and Radiology etc as required. The Acute Aortic Dissection Diagnosis improvement work is in liaison with the colleagues from across the East Midlands Aortic Network to ensure inclusion of best practice and learning from other regional centres across the network and National Programmes. We would like to extend our apologies and condolences to the family and friends of the late David Charles Noel Jones and hope this response provides assurance of our commitment to improving patient safety and experience.

Report sections

Investigation and inquest

On 12 August 2024 an inquest was opened into the death of David Charles Noel Jones, aged 65. The inquest concluded on 2 September 2025. I made a narrative determination at inquest that he died as a result of an aortic dissection.

Circumstances of the death

Mr Jones had attended hospital following an episode of dizziness. He was reviewed in the Emergency Department and noted to have low blood pressure and a low pulse rate. He was monitored within Resus before being stepped down to Majors whilst awaiting admission to ward B3 for monitoring of his blood pressure and kidney function. Mr Jones had an incident of chest pain and sweatiness whilst mobilising when he was in Majors. That was not brought to the attention of a senior doctor and did not result in a further clinical assessment and consideration of further investigations within resus. Those likely further investigations may well have revealed the presence of an aortic dissection. Mr Jones remained as an inpatient in hospital until the following day when he was discharged and sadly died later that day from the effects of the aortic dissection.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0514
Date of report: 14 October 2025
Coroner: Nathanael Hartley
Coroner area: Nottingham and Nottinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Dec 2025 (estimated).

Sent to

Nottingham University Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.