Malcolm Budd

It has come to my attention that, despite reassurances in another, very similar case in this jurisdiction, the Acute Aortic Dissection Pathway Toolkit (dated March 2022) has not been implemented in the East Midlands. This is a toolkit which aims to standardise and improve aortic dissection pathways and to establish a framework for regional networks, including governance structure, clearly defined patient pathways, multidisciplinary team processes and formal outcome monitoring arrangements.  I am aware that there was an intention to facilitate the development of a comprehensive regional Standard Operating Procedure (SOP), consistent with arrangements already established in other regions. To date no comprehensive regional SOP for the management of acute aortic dissection has been formally implemented in the East Midlands. I believe that the lack of this agreement between local hospitals has led to delays in transferring patients with acute aortic dissection from tertiary hospitals within the East Midlands to the University Hospitals of Leicester (Glenfield) where potential lifesaving surgical treatment can take place, as is the case in this investigation and in a previous inquest that was heard by me on the 21 April 2026. Both patients were received by Glenfield Hospital in extremis and died before any operation could take place. I am aware of further instances where patients have been redirected to Glenfield only after significant deterioration in their condition despite the clinical understanding that, in acute aortic dissection, each hour of delay is associated with a measurable increase in mortality risk.