NHS England
NHS / Health Body
Noted
NHS England states that the responsibility for clinical guidelines lies with NICE and the Royal Colleges, and highlights existing guidance from those bodies on AAA and acute pancreatitis. They note internal discussions and the sharing of learning from PFD reports nationally. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Thomas Geoffrey Wakefield who died on 23 September 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 2024 concerning the death of Thomas Geoffrey Wakefield on 23 September 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Thomas’ family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Thomas’ care have been listened to and reflected upon.
Your Report raises the concern that existing clinical guidance does not provide the adequate caution about the recognised risk or diagnoses for abdominal aortic aneurysm (AAA) and acute pancreatitis.
The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.
Notwithstanding the above, clinical leads within our organisation have reviewed the concerns raised by the coroner. As well as the NICE guidance referenced in your Report, the Royal College of Emergency Medicine (RCEM) and the British Society of Gastroenterology also produce guidance on AAA and acute pancreatitis and outline when AAA should be considered and the importance of ruling it out in individuals with presenting symptoms of both conditions. Some relevant sections are referenced below:
The NICE guideline (ng165) for Abdominal aortic aneurysm: diagnosis and management states:
“1.1.7 Think about the possibility of ruptured AAA in people with new abdominal and/or back pain, cardiovascular collapse, or loss of consciousness. Be aware that ruptured AAA is more likely if they also have any of the following risk factors:
• an existing diagnosis of AAA
• age over 60
• they smoke or used to smoke National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
12 June 2024
• history of hypertension.
1.1.8 Be aware that AAAs are more likely to rupture in women than men.
1.1.9 Offer an immediate bedside aortic ultrasound to people in whom a diagnosis of symptomatic and/or ruptured AAA is being considered. Discuss immediately with a regional vascular service if:
• the ultrasound shows an AAA or
• the ultrasound is not immediately available or it is non-diagnostic, and an AAA is still suspected.”
The RCEM best practice guidance for the Management and transfer of patients with a diagnosis of ruptured abdominal aortic aneurysm to a specialist vascular centre states:
"1. A clinical diagnosis of ruptured abdominal aortic aneurysm (rAAA) should be considered:
• In patients over the age of 50 years presenting with abdominal/back pain AND hypotension;
• In patients with a known AAA and symptoms of either abdominal/back pain OR hypotension/collapse;
• In patients where an alternative diagnosis is considered more likely on clinical grounds, rAAA still must be excluded, with radiological confirmation made prior to referral" The BSG guidelines for the Management of acute pancreatitis state:
"The value of ultrasonography lies in its ability to demonstrate gall bladder stones and dilatation of the common bile duct, as well as other pathology unrelated to the pancreas such as abdominal aortic aneurysm. CT is occasionally indicated for diagnosis, if clinical and biochemical findings are inconclusive, especially when abdominal signs raise the possibility of an alternative abdominal emergency, such as a perforation or infarction of the bowel."
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 2024 concerning the death of Thomas Geoffrey Wakefield on 23 September 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Thomas’ family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Thomas’ care have been listened to and reflected upon.
Your Report raises the concern that existing clinical guidance does not provide the adequate caution about the recognised risk or diagnoses for abdominal aortic aneurysm (AAA) and acute pancreatitis.
The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.
Notwithstanding the above, clinical leads within our organisation have reviewed the concerns raised by the coroner. As well as the NICE guidance referenced in your Report, the Royal College of Emergency Medicine (RCEM) and the British Society of Gastroenterology also produce guidance on AAA and acute pancreatitis and outline when AAA should be considered and the importance of ruling it out in individuals with presenting symptoms of both conditions. Some relevant sections are referenced below:
The NICE guideline (ng165) for Abdominal aortic aneurysm: diagnosis and management states:
“1.1.7 Think about the possibility of ruptured AAA in people with new abdominal and/or back pain, cardiovascular collapse, or loss of consciousness. Be aware that ruptured AAA is more likely if they also have any of the following risk factors:
• an existing diagnosis of AAA
• age over 60
• they smoke or used to smoke National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
12 June 2024
• history of hypertension.
1.1.8 Be aware that AAAs are more likely to rupture in women than men.
1.1.9 Offer an immediate bedside aortic ultrasound to people in whom a diagnosis of symptomatic and/or ruptured AAA is being considered. Discuss immediately with a regional vascular service if:
• the ultrasound shows an AAA or
• the ultrasound is not immediately available or it is non-diagnostic, and an AAA is still suspected.”
The RCEM best practice guidance for the Management and transfer of patients with a diagnosis of ruptured abdominal aortic aneurysm to a specialist vascular centre states:
"1. A clinical diagnosis of ruptured abdominal aortic aneurysm (rAAA) should be considered:
• In patients over the age of 50 years presenting with abdominal/back pain AND hypotension;
• In patients with a known AAA and symptoms of either abdominal/back pain OR hypotension/collapse;
• In patients where an alternative diagnosis is considered more likely on clinical grounds, rAAA still must be excluded, with radiological confirmation made prior to referral" The BSG guidelines for the Management of acute pancreatitis state:
"The value of ultrasonography lies in its ability to demonstrate gall bladder stones and dilatation of the common bile duct, as well as other pathology unrelated to the pancreas such as abdominal aortic aneurysm. CT is occasionally indicated for diagnosis, if clinical and biochemical findings are inconclusive, especially when abdominal signs raise the possibility of an alternative abdominal emergency, such as a perforation or infarction of the bowel."
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.