Source · Prevention of Future Deaths

George Leonard Parkes

Ref: 2013-0252 Date: 4 Oct 2013 Coroner: Sarah Ormond-Walshe Area: Birmingham and Solihull Responses identified: 0 / 1 View PDF

Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.

Date 4 Oct 2013
56-day deadline 23 Mar 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.
View full coroner's concerns
attach the summing up in relation to this case which essentially involves the situation where a patient with an abdominal aortic aneurysm was "lost to follow up"_ The consequences were that it meant that his aneurysm became so big that it ruptured and he died. Potentially, this was a preventable death as if he was eligible, he would have been given the opportunity of having fenestrated endovascular repair which probably have meant he would not have died when he did, It has been suggested to me by witnesses that having a specialist nurse clinic (enabling open monitoring of patients with abdominal aortic aneurysms) and dedicated procedure databaselregister, would prevent this situation happening again. The guidance from the Chief Coroner is that in writing these Reports, the Coroner does not make a very specific recommendation and do not in this case, however; support the Consultant Vascular Surgeons at the Queen Elizabeth Hospital (specifically _ in actions such as the nurse clinic being set up, to prevent future loss of life, and any other measure(s) which will prevent future "lost to follow-up" situations_

Report sections

Investigation and inquest
On 4lh January 2013 commenced an investigation into the death of George Leonard Parkes, age 84 The investigation concluded at the end of the inquest on 4lh October 2013. The conclusion of the inquest was: Medical cause of death a
Circumstances of the death
Please see attached. being
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action: would the do,
Copies sent to
CASE NUMBER:_0029/2013

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Report details

Reference
2013-0252
Date of report
4 October 2013
Coroner
Sarah Ormond-Walshe
Coroner area
Birmingham and Solihull

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: 23 Mar 2014 (estimated).

Sent to

University Hospitals Birmingham NHS Foundation Trust

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