Source · Prevention of Future Deaths
David Birtwistle
Ref: 2017-0139
Date: 18 Apr 2017
Coroner: Terence Moore
Area: Avon
Responses identified: 0 / 2
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A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
Date
18 Apr 2017
56-day deadline
4 Sep 2017 est.
Responses identified
0 of 2
Coroner's concerns
A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
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A national review of serious incidents and near misses in similar "front door"
Report sections
Investigation and inquest
On 30lh November 2016 an investigation commenced into the death of David Lee BIRTWISTLE, Aged 44. The investigation concluded at the end of the inquest on March 2017. The conclusion was that the medical cause of death was I(a) Pulmonary embolism; I(b) vein thrombosis and cardiomyopathy The conclusion as to the death was a narrative conclusion which read: Mr: Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death: This meant that further tests, which have led to an earlier diagnosis of his condition, were not done_
Circumstances of the death
Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days to his death: This meant that further tests, which could led to an earlier diagnosis of his condition, were not done_ No 111 referral information was available to "front door" or the ED_
Action should be taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action_ 23rd Deep could prior have and
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Report details
- Reference
- 2017-0139
- Date of report
- 18 April 2017
- Coroner
- Terence Moore
- Coroner area
- Avon
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2017 (estimated).
Sent to
- Brisdoc
- NHS, University Hospital Bristol NHS Trust