Source · Prevention of Future Deaths
Christina Smith
Ref: 2017-0107
Date: 4 Apr 2017
Coroner: Tony Williams
Area: Somerset
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner identified a breakdown in communication leading to Mrs Smith and her GP not being informed of a thoracic aneurysm, which consequently was not placed under surveillance.
Date
4 Apr 2017
56-day deadline
11 Jul 2017 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner identified a breakdown in communication leading to Mrs Smith and her GP not being informed of a thoracic aneurysm, which consequently was not placed under surveillance.
View full coroner's concerns
_ (1) A report on Mrs Smith of 2011 identified both an Abdominal Aneurysm and a Thoracic Aneurysm. It appears Mrs Smith was never told of the existence of the Thoracic Aneurysm. appears Mrs Smith's GP was never told of the existence of the Thoracic Aneurysm.
(2) Mrs Smith's Abdominal Aneurysm was placed under surveillance so as to monitor any possible increase in size Mrs Smith's Thoracic Aneurysm was not placed under surveillance.
(3) There appears to have been a breakdown in communication with regard to advising both Mrs Smith and her GP as to the existence of the Thoracic Aneurysm_ Old Municipal Building; Corporation Street; Taunton; Somerset, TAI 4AQ Tel Fax 01823 355060 Tony Tony being Only
(2) Mrs Smith's Abdominal Aneurysm was placed under surveillance so as to monitor any possible increase in size Mrs Smith's Thoracic Aneurysm was not placed under surveillance.
(3) There appears to have been a breakdown in communication with regard to advising both Mrs Smith and her GP as to the existence of the Thoracic Aneurysm_ Old Municipal Building; Corporation Street; Taunton; Somerset, TAI 4AQ Tel Fax 01823 355060 Tony Tony being Only
Report sections
Investigation and inquest
On 27/04/2016 commenced an investigation into the death of Christina Ingrid Smith, 70 The investigation concluded at the end of the inquest on 15/02/2017 . The conclusion of the inquest was Natural Causes On 31st March 2016 at Sherborne Mrs Smith died from a naturally occurring haemorrhage. Intrathoracic Haemorrhage Ruptured Dissecting Aortic Aneurysm Chronic Pulmonary Obstructive Disease
Circumstances of the death
On 30lh March 2016 Mrs Smith was referred by her GP to the Emergency Department (ED) of Yeovil District Hospital (YDH). Those assessing Mrs Smith in the ED were not aware of her under review for a known Abdominal Aneurysm (AA): An ultrasound scan was requested to determine if Mrs Smith had a gallbladder disease On 30lh March 2016 Mrs Smith returned to YDH when the scan was performed and the results received . By this time those assessing Mrs Smith knew of the AA and were satisfied it had not changed in size. A CT scan was requested, The CT scan was planned for April 2016. Overnight Mrs Smith deteriorated and died at home Post Mortem confirmed the cause of death as set out above.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Similar PFD reports
Report details
- Reference
- 2017-0107
- Date of report
- 4 April 2017
- Coroner
- Tony Williams
- Coroner area
- Somerset
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: 11 Jul 2017 (estimated from the Judiciary.uk publication date).
Sent to
- Bute House Surgery
- Yeovil District Hospital