Source · Prevention of Future Deaths
David Evans
Ref: 2017-0134
Date: 20 Apr 2017
Coroner: Philip Spinney
Area: South Wales Central
Responses identified: 0 / 1
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An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
Date
20 Apr 2017
56-day deadline
16 Jun 2017
Responses identified
0 of 1
Coroner's concerns
An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
View full coroner's concerns
(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision: (2) The evidence_revealed that records of FAST_ultrasound examinations are not_ and and routinely stored preventing evaluation of scans f0 be undertaken aiter the event The evidence revealed that where an Abdlominal Aortic Aneurysm (AAA) is iclentified in the emergercy department by a FAST ultrasound examination and patient is symptomatic there should always be an appropriate escalation of care
Report sections
Investigation and inquest
On 25 January 2017 | commenced an investigation into the death of David Thomas Evans. The investigation concluded at the end of the inquest on the 20 April 2017. The conclusion of the inquest was a narrative conclusion as follows: David Thomas Evans died as a result of complications following a ruptured thoraco-abdominal aneurysm.
Circumstances of the death
On 15 January 2017 David Thomas Evans presented at University Hospital Wales Emergency Department with severe abdominal pain: Whilst in hospital he underwent an ultrasound scan of the abdominal aorta that revealed a diameter 0f 4Omm; no further investigation of the aorta was conducted he was discharged with a diagnosis of diverticulitis and given antibiotics His abdominal pain persisted and on 22 January 2017 he was admitted to University Hospital Wales_ An examination revealed a ruptured aortic aneurysm: Mr Evans underwent emergency surgery that revealed a significant amount of ischaemic bowel from which he was unable to survive_ He sadly died later that day_
Action should be taken
(0) Consideration should be given ko reviewing your procedures related t0 the training and the supervision Of those undergoing training in conducting FAST Ultrasound examinations (2) Consideration should be given to reviewing your procedures for recording the outcome 0f FAST ultrasound examinations_ (3) Consideration should be given to reviewing your procedures surrounding the management Of symptomatic patients where an AAA has been identified by a FAST ultrasound examination: In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
Inquest conclusion
David Thomas Evans died as a result of complications following a ruptured thoraco-abdominal aneurysm.
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Report details
- Reference
- 2017-0134
- Date of report
- 20 April 2017
- Coroner
- Philip Spinney
- Coroner area
- South Wales Central
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Jun 2017.
Sent to
- Cardiff and Vale University Health Board