Vilmantas Venskutonis

On 09/10/2019 commenced an investigation into the death of Vilmantas Venskutonis, aged 30. The investigation concluded at the end of the inquest on 07/04/2021. The conclusion of the inquest was that Vilmantas Venskutonis died as a result of Natural causes, the medical cause of death being: Ia. Acute Myocardial Infarction 1b. Thrombosis and Occlusion of the Left Anterior Descending Branch of the Coronary 1c. CIRCUMSTANCES OF THE DEATH
1.Admitted to Pilgrim Hospital with chest pains
2.Chest pains intensified
3.Transfererred to Lincoln County Hospital 4.11 separate intervention opportunities acknowledged that were missed at the Pilgrim
5. Died in County Hospital 5_ CORONERS CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you: Artery kAuthorisingUserFullNamex kAuthorisingUserAppointmentr County of Lincolnshire The MATTERS OF CONCERN are as follows_ refer to the action plan dated_ December 2019 that was attached to the Sl report, Lead Investigator, Dr (Cardiology). The commencement of the plan is January 2020. There are nine points t0 this plan, need to know if the plan has been implemented in full to prevent further deaths with implementation dates for all 9 points_ If implemented in full or_in part_please state_ reason why identifying each_point_ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16/06/2021_ I, the Coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed: 8_ COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons (a) NOK am also under a duty to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner Date: <AuthorisedDateShortv kAuthorisingUserSignaturen C (AuthorisingUserFullNamen kAuthorisingUserAppointment) 21 /+l21: not

1.Admitted to Pilgrim Hospital with chest pains
2.Chest pains intensified
3.Transfererred to Lincoln County Hospital 4.11 separate intervention opportunities acknowledged that were missed at the Pilgrim
5. Died in County Hospital 5_

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action