Source · Prevention of Future Deaths

Noel Jones

Ref: 2015-0155 Date: 22 Apr 2015 Coroner: Geraint Williams Area: Worcestershire Responses identified: 1 / 1 View PDF

Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.

Date 22 Apr 2015

56-day deadline 17 Jun 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.

View full coroner's concerns

being from being have Royal delay

(1) Evidence was given that had Mr Jones been accepted by Worcestershire Royal Hospital earlier he would the balance of probability have survived this episode (2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology (3)

Responses

1 respondent

Worcestershire NHS Trust NHS / Health Body

17 Jun 2015 PDF

Action Taken

The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer. (AI summary)

View full response

Dear Mr Williams Re: Noel Owen Jones deceased Regulation 28: Report to Prevent Future Deaths am writing with reference to your letter dated 22 April 2015 in which you raised two concerns regarding Trust procedures following evidence which you heard at the inquest into the death of Mr Jones. As a result of your letter confirm that have reviewed the Trust's processes in respect of the following action: Review the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who need to be transferred in from elsewhere_ Attached is my response that sets out in detail the Trust's procedures and the actions which have been taken in response to your concerns: hope that this information provides assurance to you: However; if you require any additional information please do not hesitate to contact me

Report sections

Investigation and inquest

On 17th November 2014 commenced an investigation into the death of Noel Owen JONES then aged 77 years The investigation concluded at the end of the inquest on 16 April 2015. The conclusion of the inquest was he died as the result of known complication of necessary surgery the medical cause of death 1(a) Shock; 1(b) haemorrhage left iliac artery and perforated descending colon following cystectomy, 2, atherosclerosis, inhalation of gastric contents, ischaemic heart disease, cancer of the upper rectum irradiation for testicular cancer

Circumstances of the death

On 2nd October 2014 Mr Jones underwent surgery at the Alexandra hospital. He was later discharged before admitted on two occasions to the Hereford County Hospital: It is clear that upon his admission to Hereford on 15th November 2014 he was severely unwell and had sustained an internal haemorrhage The clinicians at Hereford struggled to Mr Jones admitted to a variety of hospitals including Worcestershire Hospital. Ultimately when Mr Jones appeared to be in extremis Worcestershire Royal Hospital agreed to accept him and he was rushed there by ambulance but died shortly after his arrival: It appears that there was a four hour between the first telephone call to Worcestershire Royal asking for him to be admitted and his ultimate acceptance_

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 by reviewing the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who needs to be transferred in from elsewhere_

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Shared signals

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Report details

Reference: 2015-0155
Date of report: 22 April 2015
Coroner: Geraint Williams
Coroner area: Worcestershire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jun 2015 (estimated).

Sent to

Worcestershire Acute Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.