Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0134, written 20 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2017 |
|---|---|
| Reference | 2017-0134 |
| Deceased | David Evans |
| Coroner | Philip Spinney |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS
“REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 21 April 2017 IS BEING SENT TO:
Interim Chief Executive, Cardiff and Vale
University Health Board
CORONER
| am Philip Charles SPINNEY, Area Coroner, for the coroner area of South Wales
Central.
CORONER'S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 25 January 2017 | commenced an investigation into the death of David Thomas
Evans. The investigation concluded at the end of the inquest on the 20 April 2017. The
conclusion of the inquest was a narrative conclusion as follows:
David Thomas Evans died as a result of complications following a ruptured thoraco-
abdominal aneurysm.
CIRCUMSTANCES OF THE DEATH
On 15 January 2017 David Thomas Evans presented at University Hospital Wales
Emergency Department with severe abdominal pain. Whilst in hospital he underwent an
ultrasound scan of the abdominal aorta that revealed a diameter of 40mm, no further
investigation of the aorta was conducted and he was discharged with a diagnosis of
diverticulitis and given antibiotics. His abdominal pain persisted and on 22 January
2017 he was admitted to University Hospital Wales. An examination revealed a ruptured
aortic aneurysm. Mr Evans underwent emergency surgery that revealed a significant
amount of ischaemic bowel from which he was unable to survive. He sadly died later
that day.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. ~
(1) The evidence revealed that the Dr that conducted the Focussed Assessment
with Sonography for Trauma (FAST) Ultrasound examination had not completed
the necessary training and should have conducted the scan under supervision.
(2) The evidence revealed that records of FAST ultrasound examinations are not
routinely stored preventing evaluation of scans to be undertaken aiter the event.
(3) The evidence revealed that where an Abdominal Aortic Aneurysm (AAA) is
identified in the emergency department by a FAST ultrasound examination and
a patient is symptomatic there should always be an appropriate escalation of
care.
ACTION SHOULD BE TAKEN
(1) Consideration should be given to reviewing your procedures related to the
training and the supervision of those undergoing training in conducting
FAST Ultrasound examinations.
(2) Consideration should be given to reviewing your procedures for recording
the outcome of FAST ultrasound examinations.
(3) Consideration should be given to reviewing your procedures surrounding
the management of symptomatic patients where an AAA has been
identified by a FAST ultrasound examination.
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16 June 2017, |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner
{am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. pony may make representations to me, the coroner, at the time of your
diyOut the release or the publication of your response by the Chief Coroner.
if
iz
Mr Philip Spinney
HM Area Coroner
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