Thomas Wakefield

Jacqueline Devonish  
Cheshire Coroner’s Court 
The West Annexe 
Town Hall 
Sankey Street 
Warrington 
Cheshire  

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

12 June 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Thomas Geoffrey 
Wakefield who died on 23 September 2023.   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 
2024 concerning the death of Thomas Geoffrey Wakefield on 23 September 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Thomas’ family and loved ones. NHS England are 
keen  to  assure  the  family  and  the  coroner  that  the  concerns  raised  about  Thomas’ 
care have been listened to and reflected upon.   

Your  Report raises the concern that  existing  clinical  guidance does not  provide the 
adequate  caution  about  the  recognised  risk  or  diagnoses  for  abdominal  aortic 
aneurysm (AAA) and acute pancreatitis.  

The responsibility for the relevant clinical guidelines does not fall within the remit of 
NHS  England,  who  are  independent  of  the  National  Institute  for  Health  and  Care 
Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that 
the coroner refer their concerns to the responsible organisations.  

Notwithstanding the above, clinical leads within our organisation have reviewed the 
concerns  raised  by  the  coroner.  As  well  as  the  NICE  guidance  referenced  in  your 
Report, the Royal College of Emergency Medicine (RCEM) and the British Society of 
Gastroenterology also produce guidance on AAA and acute pancreatitis and outline 
when AAA should be considered and the importance of ruling it out in individuals with 
presenting  symptoms  of  both  conditions.  Some  relevant  sections  are  referenced 
below:  

The  NICE  guideline  (ng165)  for  Abdominal  aortic  aneurysm:  diagnosis  and 
management states:  

“1.1.7 Think about the possibility of ruptured AAA in people with new abdominal and/or 
back pain, cardiovascular collapse, or loss of consciousness.  
Be aware that ruptured AAA is more likely if they also have any of the following risk 
factors:  
 • an existing diagnosis of AAA  
 • age over 60  
 • they smoke or used to smoke  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
  • history of hypertension.  
 1.1.8 Be aware that AAAs are more likely to rupture in women than men.  
 1.1.9 Offer an immediate bedside aortic ultrasound to people in whom a diagnosis of 
symptomatic and/or ruptured AAA is being considered.  
 Discuss immediately with a regional vascular service if:  
 • the ultrasound shows an AAA or  
 • the ultrasound is not immediately available or it is non-diagnostic, and an AAA is still 
suspected.” 

The RCEM best practice guidance for the Management and transfer of patients 
with a diagnosis of ruptured abdominal aortic aneurysm to a specialist vascular 
centre states:  

"1.  A  clinical  diagnosis  of  ruptured  abdominal  aortic  aneurysm  (rAAA)  should  be 
considered:  
•  In  patients  over  the  age  of  50  years  presenting  with  abdominal/back  pain  AND 
hypotension;  
•  In  patients  with  a  known  AAA  and  symptoms  of  either  abdominal/back  pain  OR 
hypotension/collapse;  
•  In  patients  where  an  alternative  diagnosis  is  considered  more  likely  on  clinical 
grounds,  rAAA  still  must  be  excluded,  with  radiological  confirmation  made  prior  to 
referral" 

The BSG guidelines for the Management of acute pancreatitis state:  

"The value of ultrasonography lies in its ability to demonstrate gall bladder stones and 
dilatation  of  the  common  bile  duct,  as  well  as  other  pathology  unrelated  to  the 
pancreas  such  as  abdominal  aortic  aneurysm.  CT  is  occasionally  indicated  for 
diagnosis,  if  clinical  and  biochemical  findings  are  inconclusive,  especially  when 
abdominal signs raise the possibility of an alternative abdominal emergency, such as 
a perforation or infarction of the bowel." 

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

 
 
 
 
  
  
 
 
 
 
 
 Yours sincerely,  

National Medical Director

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

+44 (0)300 323 0140 

14 August 2025 

Jacqueline Devonish 
HM Senior Coroner  
The Coroner’s Court 
Museum Street,  
Warrington, 
Cheshire,  
WA1 1JX 

Sent via email: 

Our reference:

Dear Ms Devonish 

Re: Regulation 28 Prevention of Future Deaths Report (Thomas Geoffrey Wakefield) 

Further to your regulation 28 report dated 2 May 2024 regarding the very sad death of 

Thomas Geoffrey Wakefield, I am writing to update on progress taken since our response 

dated 25 June 2024. In this we committed to  amend our guideline for pancreatitis (NG104) 

from “Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, 

which are usually raised” to ‘A diagnosis of acute pancreatitis is supported by testing blood 

lipase or amylase levels, which are usually raised, although raised blood lipase or amylase 

levels may occur in other conditions’. 

Our apologies for the delay in providing an update. We can confirm that this action has now 

been completed via a post-publication amendment to the guideline. Our sympathies continue 

to be with Mr Wakefield’s family and we hope this update and action taken is of some 

reassurance to them.  

Yours Sincerely, 

Professor 
Chief Medical Officer, Deputy CEO and Interim Director of the Centre for Guidelines, NICE 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
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2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

25 June 2024  

Jacqueline Devonish 
HM Senior Coroner  
The Coroner’s Court 
Museum Street,  
Warrington, 
Cheshire,  
WA1 1JX 

Dear Ms Devonish 

Re: Regulation 28 Prevention of Future Deaths Report (Thomas Geoffrey 
Wakefield) 

I write in response to your regulation 28 report dated 2 May 2024 regarding the very 
sad  death  of  Thomas  Geoffrey  Wakefield.  I  would  like  to  express  my  sincere 
condolences to Mr Wakefield’s family.   

Our patient safety leads at NICE have discussed the contents of your report and the 
summary  information  given  relating  to  the  care  given  to  Mr  Wakefield,  while 
considering the relevant published NICE guidance on this topic. 

Our clinical advisers have highlighted that  our guideline Abdominal aortic aneurysm: 
diagnosis  and  management  (NG156)  does  provide  details    of  the  epidemiological 
factors  that  should  be  considered  as  pointers  towards  the  diagnosis,  and  I  have 
included a link to these factors below:  

Recommendations  |  Abdominal  aortic  aneurysm:  diagnosis  and  management  | 
Guidance | NICE.  

In  addition,  our  guideline  Pancreatitis  (NG104)  provides  advice  on  the  treatment  of 
pancreatitis and gives a short outline on diagnostic features. The guidance explains 
that “people with acute pancreatitis usually present with sudden-onset abdominal pain. 
Nausea and vomiting are often present and there may be a history of gallstones or 
excessive alcohol intake. Typical physical signs include epigastric tenderness, fever 
and tachycardia. Diagnosis of acute pancreatitis is confirmed by testing blood lipase 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 or amylase levels, which are usually raised. If raised levels are not found, abdominal 
CT may confirm pancreatic inflammation.” 

Our patient safety leads have commented that. Although it is not a recommendation, 
the  guideline  also  states  that  a  raised  amylase  level  confirms  the  diagnosis  of 
pancreatitis. We feel this may be misleading as this can be caused by other conditions, 
including mesenteric ischaemia due to an aortic aneurysm.  

We are therefore going to take the following action:  

Review section 1.2 of the guideline on pancreatitis, and consider whether the wording 
should be changed from:  

“Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, 
which are usually raised” to ‘A diagnosis of acute pancreatitis is supported by testing 
blood lipase or amylase levels, which are usually raised, although raised blood lipase 
or amylase levels may occur in other conditions’.   

It is important to add that NICE guidelines cannot cover all clinical circumstances, and 
each guideline has a clearly set out and agreed scope. Our guidelines relate to specific 
medical  conditions,  and  therefore  cannot  cover  all  possible  differential  diagnoses.  
Responsibility  for  decisions  on  the  most  appropriate  treatment  stays  with  individual 
clinicians, whose role it is to use their professional experience and training  to make 
the  correct  decision  on  treatment  for  each  of  their  patients.  NICE  guidelines  are  a 
practical  tool  to  be  used  in  conjunction  with  and  not  as  a  substitute  for  clinical 
judgement.  

I hope this information and the action that we are taking is helpful, and would like to 
reiterate my sincere condolences to Mr Wakefield’s family.  

Yours sincerely, 

Chief Executive 

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