Source · Prevention of Future Deaths

John Keen

Ref: 2026-0291 Date: 3 Jun 2026 Coroner: Nicholas Lane Area: Devon, Plymouth and Torbay 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified inadequate analysis by SWAST NHS, noting paramedics did not identify a potential aortic dissection given the patient's history and symptoms, which delayed life-saving surgery. The clinical review also contained an error in recording the patient's aneurysm type.

Date 3 Jun 2026

56-day deadline 8 Oct 2026 est. estimated from the Judiciary.uk publication date

Responses identified 2 of 2

Coroner's concerns

AI summary

The coroner identified inadequate analysis by SWAST NHS, noting paramedics did not identify a potential aortic dissection given the patient's history and symptoms, which delayed life-saving surgery. The clinical review also contained an error in recording the patient's aneurysm type.

View full coroner's concerns

SWAST NHS
1)It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS, with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.

All clinical witnesses who gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection.

Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer. If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.

SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred.

The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset radiating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation. The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.

If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians, and do not take steps to try and learn from these incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.

2) Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (it lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC.

Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views. At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.

All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:

– there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.

– in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk.                          This appears to be unhelpful.

– hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.

– overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.

JRCALC
1) At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.

All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:

– there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.

– in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk.

This appears to be unhelpful.
– hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.

– overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.

Responses

2 respondents

Association of Ambulance Chief Executives

NHS / Health Body

Indexed date: 8 Jul 2026 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Association of Ambulance Chief Executives (AACE) brought the coroner's concerns to the attention of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) clinical leads for vascular emergencies. • JRCALC clinical leads are reviewing and will revise sections of the vascular emergencies guideline, including those on aortic aneurysms and aortic dissections, to improve clarity and user-friendliness. • The AACE stated it would improve the formatting of the 'aortic dissection detection risk score' table and amend wording regarding hypotension as a risk factor.

View full response

Dear Mr Lane JOHN SOUTHAM KEEN (DECEASED) I am writing in response to the preventing future deaths report in my capacity as managing director of the Association of Ambulance Chief Executives (AACE). On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Keen. AACE is a private company owned by the English and Welsh Ambulance NHS trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and assists with the implementation of nationally agreed policy. Our primary focus is the ongoing development of UK NHS ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possesses the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services, however, it has national influence via the regular meetings of ambulance chief executives and chairs along with a network of national specialist groups. We respond in relation to your proposed matters of concern: Vascular emergencies guideline has been considered to be confusing, potentially contradictory and not at all user-friendly for paramedics. The JRCALC guidelines are advisory and have been developed to assist paramedics working in UK ambulance services in making decisions about the management of patients’ health, including treatments and to support clinical practice. We recognise that the guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore, we expect that paramedics using JRCALC guidelines ensure they have the appropriate knowledge and skills to enable suitable interpretation. Your matter of concern was brought to the attention of JRCALC, and specifically to the clinical leads for the vascular emergencies guideline. These clinical leads are our expert advisors who have a background of vascular and surgical knowledge and have offered to support this work. They= are currently reviewing the sections of guidance that relate to aortic aneurysms and aortic dissections. As part of this process of review, we will ensure paramedic input so the guidance is as user friendly as possible. We had an initial meeting on the 22 June 2026 to discuss your concerns which I have summarised below.

1. Section titled ‘aortic aneurysms’ This section will be fully revised and updated aiming to remove any confusion and add clarity.
2. The ‘aortic dissection detection risk score’ The detection risk score table was included in a revision of the guideline in 2024. We aimed to assist in identifying the more subtle signs of vascular emergencies that may be missed. As this clinical risk stratification tool is not specifically designed for pre-hospital use, and only validated for hospital assessment, calculating a risk score would lead to actions that cannot be undertaken in the pre- hospital setting, for example D-dimer testing. The tool was modified so that if any score was positive in any column, it was recommended that the patient should be conveyed to hospital. We recognise this information may be improved with updated formatting of the table.
3. Hypotension as a risk factor The review group will amend the wording to make the relevance of high and low blood pressure clearer.
4. This guidance unhelpfully long-winded & compares unfavourably to other documents used in similar clinical situations On initial review of the guideline, we agree with this assessment. Our specialist advisors have recommended we update the section on ‘aortic aneurysms’. We are considering developing a new algorithm to streamline key information and actions for clinicians. Our intent is to complete our review and subsequent update of the vascular emergencies guidance. The revised guideline will be presented to JRCALC for approval, and then for final ratification by the national ambulance services medical directors’ group (NASMeD). New and updated guidelines are released onto the JRCALC App at regular intervals throughout the year. Ambulance services are given at least four weeks’ notice of planned updates via senior clinicians so that they can prepare accordingly and consider any local education that may be required to support new guidance. I hope this is helpful. Please do not hesitate to contact me should you require any further information.

South Western Ambulance Service NHS Trust

NHS Trust

Letter dated 14 Jul 2026 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust apologised for inadequacies in its initial clinical review and undertook a review of its processes. • The Trust will continue to strengthen clinical oversight and scrutiny of investigation reports. • The Trust added an information box to the JRCALC national vascular guideline and introduced improved remote clinician support for ambulance clinicians.

View full response

Dear Mr Lane

Prevention of Future Deaths Report following the inquest touching the death of Mr John Southam Keen

I am writing on behalf of South Western Ambulance Service NHS Foundation Trust (thereafter referred to as the Trust) in response to a Regulation 28 report to prevent future deaths, issued in relation to death of Mr John Southam Keen.

I am the Trust’s Executive Medical Director, a Consultant in Anaesthesia and Intensive Care Medicine for United Hospitals Bristol and Weston NHS Foundation Trust, and a Helicopter Emergency Medical Service (HEMS) doctor for Great Western Air Ambulance. I additionally sit as Co-Chair of JRCALC.

I would firstly like to extend my personal condolences to the family of Mr Keen at what must still be an extremely difficult time.

In your Regulation 28 report, the principle concerns you identified were in relation to the Trust investigation and subsequent report, and cogency of the national JRCALC clinical guidelines for Vascular Emergencies.

I will address these in turn:

Quality of the Internal Clinical Review

Over the past three years, the Trust has worked diligently to improve both the timeliness and quality of its investigations in extremely challenging circumstances. We are proud of the progress our teams have made in strengthening this aspect of our clinical governance processes.

However, we offer a sincere apology that the investigation undertaken in relation to the review of care afforded to Mr Keen on 19 August 2023 contained inadequacies and inconsistencies. While this does not excuse the shortcomings, it is recognised that

aneurysms, in their various forms, represent a complex clinical area in which terminology and assessment can be challenging and, at times, lead to confusion.

In response to the feedback received, we have undertaken a review of our processes. While this has not identified the need for immediate structural changes, we will continue to strengthen clinical oversight and scrutiny of investigation reports to minimise the risk of similar issues occurring in the future.

Clinical Decision-Making and Differential Diagnosis

As discussed at the inquest, the diagnosis of aneurysms cannot be made on symptoms alone in the pre-hospital setting by ambulance clinicians and requires access to diagnostic equipment. A further independent review of the clinical care was undertaken by one of our Consultant Paramedics. This review reaffirmed the views of those who gave evidence at inquest that many presenting symptoms overlap across conditions.

In this case, the attending crew applied their clinical judgement and assessed that the most likely diagnosis was a Non-ST Elevation Myocardial Infarction (NSTEMI), which informed their decision to convey the patient to Torbay Hospital.

Learning and Governance

The Trust recognises that vascular emergencies are complex and can be difficult for clinicians to identify accurately. This is an area in which the Trust has been actively engaged for several years. Our work has included supporting the development of JRCALC and AACE guideline reviews completed in 2025.

In addition, the Trust has engaged with initiatives such as Think Aorta, to explore further opportunities to raise awareness and support clinical decision-making in this area.

We acknowledge that the recognition of aneurysms will remain inherently challenging due to overlapping clinical presentations. The Medical Director and Deputy Director of Clinical Care recognise that, despite best efforts, diagnostic uncertainty will persist in some cases. Nevertheless, the Trust remains committed to supporting clinicians with the most up-to- date evidence and guidance available.

Vascular Emergencies Guidance

Following a further review after the inquest, the Trust has added an additional information box at the top of the JRCALC national vascular guideline. The box provides a clear list of the vascular centres across the South West and the hospitals which feed into them.

This information is not included in national JRCALC guidance, as it is region-specific. It is acknowledged that any guideline covering the recognition of aneurysms faces the inherent challenge posed by both atypical and overlapping symptoms. In such situations, ambulance clinicians rely on their professional judgement to determine the most appropriate clinical pathway. The Trust introduced improved remote clinician support for

ambulance clinicians during 2025. A single clinical telephone number provides rapid access to advice from a range of senior clinicians. In the case of aneurysm, a Specialist Paramedic in Critical Care would be most appropriate. Working as part of the Critical Care, function, they support circa 460 calls per month.

Engagement with JRCALC and AACE

The Trust maintains strong relationships with AACE and continues to contribute regularly to the development of JRCALC guidance through the National Ambulance Service Medical Directors Group and the National Lead Paramedic Group.

In response to the inquest, a senior member of the Trust met with the Clinical Support Managers for AACE on 17 June 2026 to review the national vascular guideline against findings.

During this discussion, AACE identified potential improvements to the language used within the clinical guidance to enhance clarity, particularly around the use of the acronym ‘AAA’. We are also aware that JRCALC are updating the Vascular guidance in line with the recommendations. The Trust is supportive of these proposed changes and will continue to engage proactively in their development.

I sincerely hope the above addresses the concerns raised.

Report sections

Investigation and inquest

On 5 September 2023 an investigation was commenced into the death of John Southam Keen. The investigation concluded at the end of the inquest hearing on 13 May 2026 at Exeter Coroner’s Court, heard by HM Area Coroner Nicholas Lane.

Section 2 of the Record of Inquest (which recorded the medical cause of Mr Keen’s death) was determined as: 1a) hypoxic brain injury 1b) type A ascending aortic dissection (operated 19/08/2023) 2) hypertension

Section 3 of the Record of Inquest (which set out how, when and where Mr Keen came by his death) was determined as: ‘John Keen had been diagnosed with a thoracic ascending aortic aneurysm in 2018, which was being managed and monitored by cardiology professionals. John suffered a dissection of this aneurysm at home in the morning on 19 August 2023, with symptoms of sudden onset chest pain radiating to his back and neck.        Paramedics attended on John and considered that he was likely suffering symptoms of acute coronary syndrome. Paramedics were informed that John had an ascending aortic aneurysm; however, for reasons unknown, they based their clinical assessment on John having an abdominal aneurysm.

If consideration had been given by attending paramedics to both John’s presenting symptoms and accurate clinical history then he would have required urgent transfer to the arterial surgery specialist unit, where he would have undergone emergency surgery.

Instead, John only arrived at this unit, Derriford Hospital, Plymouth, a number of hours later, as he was initially taken for assessment at Torbay Hospital, where imaging confirmed the dissection.

John suffered a cardiac arrest prior to surgery being undertaken at Derriford Hospital, Plymouth in the afternoon on 19 August 2023.

Although surgery was undertaken successfully, John had suffered a fatal hypoxic brain injury as a result of his cardiac arrest.

John’s life support was withdrawn and he died at Derriford Hospital on 24 August 2023.’

Section 4 of the Record of Inquest (which set out conclusions in respect of Mr Keen’s death) was determined, in narrative form, as: ‘John Keen died from the progression of a natural disease process, contributed to by delayed transfer to specialist surgical unit and consequential delay in undergoing emergency surgery.

John’s death was contributed to by neglect.’

Circumstances of the death

Mr Keen was a 70 year old man who had significant vascular disease – he had been diagnosed with hypertension a number of years previously and in 2018 he was diagnosed as having a thoracic ascending aortic aneurysm. The size of this aneurysm was monitored in the community and was felt to be fairly static and stable from diagnosis through to the summer of 2023.

Mr Keen suddenly became unwell in the morning at home on 19 August 2023.

He initially reported difficulty breathing, with sudden onset chest pain which had radiated to his back and neck. Mr Keen’s wife called 999 and spoke with the ambulance control, informing them that he was suffering from chest pain and that he had a diagnosis of an ascending aortic aneurysm.

Paramedics attended Mr Keen’s home and assessed him – they were informed that he had an ascending aortic aneurysm (both orally by Mr Keen’s wife and they were shown recent clinic documentation from the cardiology service confirming this history) and noted his clinical presentation. Paramedics considered it likely that John Keen was suffering with acute coronary syndrome and took him to the nearest acute hospital. Paramedics incorrectly recorded, on their patient record documentation, that Mr Keen had a triple AAA (abdominal aortic aneurysm), rather than an ascending aortic aneurysm.

Mr Keen was assessed by a consultant in emergency medicine at hospital and, having been informed of his background medical history (including an ascending aortic aneurysm) and noting his clinical presentation that day, they suspected an aortic dissection.

This was confirmed on imaging and Mr Keen was then transferred to the regional tertiary arterial centre for emergency surgery.

Surgery took place later on in the afternoon on 19 August; however, immediately prior to this Mr Keen went into cardiac arrest – prior to him being able to be placed on life support machine in theatre he received cardio-pulmonary resuscitation (CPR) and, during this time, had no cardiac output for around 20 minutes. Although surgery to repair the aortic dissection was carried out successfully, Mr Keen had suffered a fatal hypoxic brain injury whilst in cardiac arrest, and, following prognostic discussions with family members, active care was withdrawn and he died on 24 August 2023.

Action should be taken

In my opinion, unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe that your organisation has the power to take such action.

Copies sent to

I confirm I have sent the report to2) Torbay and South Devon NHS Foundation Trust (IP)3) Royal Devon University Healthcare NHS Foundation Trust (IP)4) University Hospitals Plymouth NHS Trust (not an IP, but were involved in care provision)

Similar PFD reports

Shared signals

Report details

Reference: 2026-0291
Date of report: 3 June 2026
Coroner: Nicholas Lane
Coroner area: Devon, Plymouth and Torbay

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Oct 2026 (estimated from the Judiciary.uk publication date).

Sent to

Association of Ambulance Chief Executives

South Western Ambulance Service NHS Trust

Source links

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Data: judiciary.uk.

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