Kevin Gilbert

On 5th February commenced an Investigation into the death of Kevin John Gilbert Cbreclusestigation concluded at the end of the Inquest onead December 201 Silbet couclusion of the Inquest was that Kevin John Gilbert died as a result of natural causes

Mr Gilbert suffered an aortic root dissection in the of 29.01.15 which diagnosed provisionally on his symptoms and then by confirmatory was after arrivalat the Accident and Emergency Department aortogram soon at William Harvey Hospital by Consultant in Accident and Emergency Medicine. Mr Gilbert was Stabilised and considered to be a suitable patient for transfer to St Thoenas' forrepair ofthe dissection because othis ag8e49 pearansfed [aCt Ofrotevantosevtol medical (mild asthma only) spoke tol previous Cardiothoracic on call SpR in surgery at St Thomas' Hospital atjust after 12.45pm who advised that he would need t0 see the images before he could Mr patienth accept Gilbert as a hhad already asked the Radiology Department to send them to St Thomas' Hospital but it wasn t until 3.4Opm that Dr Cummings confirmed td that he had received them and that Mr Gilbert could be transferred. previous 3 hours_ called Mr Cummings During the of the situation several times to stress the urgency and critical condition of his patient Atone point; he sought to escalate his request and asked to speak to Mr Cummings' Consultant; Mr Avlonitis, be told that he was in surgery and unavailable . to Mr Gilbert left William Harvey Hospital shortly after 3.4Opm in an ambulance for road journey to St Thomas' Hospital. At 3.54pm he returned to William the Hospital as he had arrested shortly after departure. AlI Harvey attempts were made to sesscitate him including pericardiocentesis and resuscitative thoracotomy but without success. His death was confirmed at 4.25pm: The cause of Mr Gilbert's death was:- 1a Acute haemopericardium 1b Aortic dissection. morning history radiology the

That all clinicians at St Thomas' Hospital who are involved in decisions to accept the transfer ofpatients to their hospital are familiar with its procedures_ pn 30.01.15 expressing his concern that the in Mr Gilbert's transfer may have contributed to his death and suggesting that alternative methods to the image transfer system eg telemedicine or a similar direct patient review system are implemented. This prompted an e mail from] all Registrars in the Cardiothoracic Surgery department dated 24" February 2015 referring to the possibility of confusion on their part regarding the process of accepting dissection referrals He confirmed that such referrals must be discussed immediately with the on-call Consultant and that there is no departmental policy to transfer the CT scan for viewing before a decision for patient transfer is made: If it is necessary to view the CT imagery in the firstplace, that decision should only be made by a Consultant (Consultant Cardiothoracic Surgeon gave evidence ing absence at the Inquest and confirmed that a Consultant must be informed by his junior staff of the request for emergency admission: Whilst it appeared that an e mail had been circulated to the Registrars by lafter Mr Gilbert's death, and receipt of letter request that all appropriate action is taken to ensure that junior clinical Surgery, 4Opm: delay delay staff are aware of the requirement that such emergencies requiring admission are discussed in the first instance with the Consultant: If it is deemed within your hospital that an e mail to this effect is sufficient; then it would seem that appropriate action has already been taken by the hospital.