Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0659, written 2 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2024 |
|---|---|
| Reference | 2024-0659 |
| Deceased | Junior Powell |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
,
Secretary of State for Health and Social Care,
Department of Health and Social Care,
39, Victoria Street,
London.
SW1H 0EU.
1
CORONER
I am Professor Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West
London
2
CORONER’S LEGAL POWERS
I 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.
3
INVESTIGATION and INQUEST
On the 26th and 27th November 2024, evidence was heard touching the death of Mr
Junior George Powell, who died on 6th September 2021 at St George’s Hospital aged 57
years.
Medical Cause of Death
1 a. Intestinal Ischaemia
b. Aortic Dissection with arterial branch occlusion
How, when, where the deceased came by his death:
Mr Powell presented at approximately 22:00 to St George’s Hospital on 3rd September of
2021 with acute onset of abdominal pain and vomiting. Initial CT scanning did not find
nay surgical cause for his symptoms. He was reviewed at 05:15 on the 4th September
2021 by the medical registrar who was concerned about his pain and worsening clinical
condition. She discussed the CT scan results with the radiologist and surgical team.
In retrospective analysis of the CT scan images subtle changes were noted that
prompted further imaging if his vascular system. This showed an abdominal aortic
dissection, reduced blow flow to the coeliac axis, the superior mesenteric artery and
renal arteries and evidence of intestinal ischaemia.
He was reviewed by the general surgeons, vascular surgeons and interventional
radiologists, by which time he deteriorated further.
He underwent resection of his bowel midmorning on 4th September 2021 but received no
surgical treatment to restore blood flow to the abdominal arteries or treat the dissection
in the aorta. He was heparinised only.
As a result, his condition continued to deteriorate and he developed increasing
ischaemic damage to his abdominal organs.
Despite further resection of his by now necrotic gall bladder and damaged bowel on 5th
September 2021, he died at 15:49 on 6th September 2021 on GITU.
If mechanical restoration of blood flow to the abdominal arteries had occurred on the
morning of 4th September 2021 or by late afternoon of 4th September 2021, on the
balance of probabilities he would not have died at this time.
As such the lack of treatment to reduced flow to the arteries via mechanical means
contributed to his death.
Conclusion of the Coroner as to the death:
Natural Causes contributed to by lack of definitive treatment of the aortic dissection.
4
Evidence relevant to the matters of concern.
Extensive evidence was taken and exhibited and some potential Regulation 28 matters
explored. Of relevance to this report:
They was a more than five hour delay before Mr Powell was reviewed by the
medical registrar and he should have been in a bed in the medical ward by
01:15. This delay was caused by shortage of staff during that night and he was
eventually seen by the medical registrar who should have been based on the
ward, not seeing patients in accident and emergency.
Evidence was taken that confirmed that such delays are usual, not just in St
George’s Hospital, and delays in admission to the wards are caused largely by
the inability to discharge patients who are fit for discharge due to lack of suitable
social support in the community.
In this case, treatment for Mr Powell was time critical and as such this delay
probably contributed to his death.
5
Matters of Concern
That delay in discharge for patients ready to be discharged due to lack of
suitable social care in the community is causing congestion in the hospital
admission process, delaying medical assessment and thus diagnosis of
conditions that need urgent treatment and increasing the likelihood of death
for such patients.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action. It is for each addressee
to respond to matters relevant to them.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. I,
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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
Wife of Mr Powell:
.
,
Chief Executive Officer,
St George’s Hospital,
Blackshaw Road,
London.
SW17 OQT.
I 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. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
2nd December 2024
Professor Fiona J Wilcox
HM Senior Coroner Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
Inner West London Coroner’s Court,
33, Tachbrook Street,
London.
SW1V 2JR
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