Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0339, written 7 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2025 |
|---|---|
| Reference | 2025-0339 |
| Deceased | David Gifford |
| Coroner | Debbie Rookes |
| Coroner area | Avon |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin His Majesty’s Senior Coroner Area of Avon 7 July 2025 REF: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Associa(cid:415)on of Ambulance Chief Execu(cid:415)ves (AACE) 1 CORONER I am Debbie Rookes, Assistant Coroner for the Coroner Area of Avon 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Jus(cid:415)ce Act 2009 and regula(cid:415)ons 28 and 29 of the Coroners (Inves(cid:415)ga(cid:415)ons) Regula(cid:415)ons 2013. 3 INVESTIGATION and INQUEST On 3 December 2024 an inves(cid:415)ga(cid:415)on was commenced into the death of David Stewart Gifford. The inves(cid:415)ga(cid:415)on concluded at the end of the inquest on 30 June 2025. The conclusion of the inquest was: Natural causes The cause of death was recorded as: 1a 1b 1c Ruptured thoraco-abdominal aortic aneurysm Fractured stent and endoleak Aortic dissection and multiple aortic aneurysms - stented Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 4 CIRCUMSTANCES OF THE DEATH David Gifford had an extensive medical history with significant co-morbidi(cid:415)es. He had a long cardiac history which included aor(cid:415)c dissec(cid:415)on, mul(cid:415)ple aor(cid:415)c aneurysms and heart failure. He first underwent surgery for aor(cid:415)c dissec(cid:415)on in 2006. He subsequently underwent further surgery on mul(cid:415)ple occasions for further sten(cid:415)ng and gra(cid:332)ing to repair addi(cid:415)onal ruptures to his aorta. He developed an endoleak which was monitored and remained stable for many years, un(cid:415)l it required surgery in 2023. Mr Gifford died on 26 November 2024 at Southmead Hospital. His death was caused by an acute ruptured abdominal aor(cid:415)c aneurysm, following the development of a fractured stent and endoleak at some point in the weeks preceding his death. It was not clear for exactly how long this endoleak had been present, or when the fracture occurred. In the weeks before his death, Mr Gifford had had mul(cid:415)ple visits to his GP surgery. He was a complex pa(cid:415)ent with a number of medical condi(cid:415)on and he had been experiencing a range of symptoms. The clinicians he saw referred him for further inves(cid:415)ga(cid:415)ons into his symptoms. In the a(cid:332)ernoon of 25 November 2024, Mr Gifford made a 999 call to the ambulance due to right-sided neck pain which radiated down his back and to his flank. He had been experiencing this pain since August 2024. Paramedics a(cid:425)ended in the evening, and a(cid:332)er an assessment, they did not think he needed to be conveyed to hospital. Worsening advice was given which resulted in Mr Gifford calling 999 again late that evening and an ambulance arrived in the early hours of 26 November 2024. He was conveyed to hospital and then transferred to Southmead Hospital, where he lost cardiac output whilst s(cid:415)ll on the trolley. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL There were concerns raised about recogni(cid:415)on of an Abdominal Aor(cid:415)c Aneurysm (AAA), and its rupture. Whilst training and knowledge focuses on iden(cid:415)fica(cid:415)on of any ‘red flag symptoms’, it is well known that a number of AAA’s do not present in this way, resul(cid:415)ng in a group of pa(cid:415)ents who are challenging to diagnose, and who may be missed. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed ma(cid:425)ers giving rise to concern. In my opinion there is a risk that future deaths will occur unless ac(cid:415)on is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Training and knowledge focuses on the classic signs and symptoms associated with an AAA. However, there are a group of pa(cid:415)ents who will not present in this way, and who may be challenging to diagnose. Whilst there may be many medical condi(cid:415)ons that could be similar, there does not seem to be much focus given to the iden(cid:415)fica(cid:415)on of vascular emergencies within training and knowledge updates. Therefore when paramedics a(cid:425)end emergencies, in the absence of classic symptoms, they may be wrongly reassured. Where a person has an extensive aor(cid:415)c history, the importance of aor(cid:415)c pathology should be considered. There has not been training or medical educa(cid:415)on for ambulance on vascular (2) emergencies for a long (cid:415)me. The evidence was that JRCALC guidelines did recently highlight the number of pa(cid:415)ents that may not present with the tradi(cid:415)onal ‘red flags’ but did not provide further guidance. This is a na(cid:415)onal issue where ambulance staff should be knowledgeable about the more subtle signs of vascular emergencies that may be missed. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 6 ACTION SHOULD BE TAKEN In my opinion ac(cid:415)on should be taken to prevent future deaths and I believe the Associa(cid:415)on of Ambulance Chief Execu(cid:415)ves, has the power to take such ac(cid:415)on. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 September 2025. I, the coroner, may extend the period. Your response must contain details of ac(cid:415)on taken or proposed to be taken, se(cid:427)ng out the (cid:415)metable for ac(cid:415)on. Otherwise you must explain why no ac(cid:415)on is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to of the deceased, and to the Chief Coroner. I have also sent a copy to South Western Ambulance Service NHS Founda(cid:415)on Trust. , son, and , daughter-in-law 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 representa(cid:415)ons to me, the coroner, at the (cid:415)me of your response, about the release or the publica(cid:415)on of your response by the chief coroner. 9 7 July 2025 Debbie Rookes Assistant Coroner Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
20 August 2025 Association of Ambulance Chief Executives 25 Farringdon Street London EC4A 4AB Debbie Rookes Assistant Coroner for the Coroner Area of Avon Dear Ms Rookes DAVID STEWART GIFFORD (DECEASED) I am writing in response to the preventing future deaths report issued to our executive officer at the Association of Ambulance Chief Executives (AACE), and I respond as our Director of Operational Development and Quality Improvement on behalf of AACE. On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Gifford. It may be helpful for us to explain that 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 implements nationally agreed policy. Our primary focus is the ongoing development of the English 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 trust chairs, along with a network of national specialist sub-groups. We respond in relation to your matter of concern (1): Training and knowledge focuses on the classic signs and symptoms associated with an AAA. However, there are a group of patients who will not present in this way, and who may be challenging to diagnose. Whilst there may be many medical conditions that could be similar, there does not seem to be much focus given to the identification of vascular emergencies within training and knowledge updates. Therefore, when paramedics attend emergencies, in the absence of classic symptoms, they may be wrongly reassured. Where a person has an extensive aortic history, the importance of aortic pathology should be considered. AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors (NASMeD) at our next national meeting. We will recommend that NASMeD consider if any further education or awareness raising regarding vascular emergencies including aortic aneurysms is required. We will also share the PFD report with the education leads of ambulance trusts, via the national education network for ambulance trusts (NENAS). Regarding your second matter of concern (2): There has not been training or medical education for ambulance on vascular emergencies for a long time. The evidence was that JRCALC guidelines did recently highlight the number of patients that may not present with the traditional ‘red flags’ but did not provide further guidance. This is a national issue where ambulance staff should be knowledgeable about the more subtle signs of vascular emergencies that may be missed. The JRCALC guidelines are advisory and have been developed to assist paramedics to make decisions about the management of the patient’s health, including treatments and to support clinical practice. The advice is intended to support the decision-making process and is not a substitute for sound clinical judgement. 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. We discussed your matters of concerns at our JRCALC meeting on the 22 July 2025. JRCALC consists of expert medical advisors including those with vascular and surgical knowledge. The committee made the decision to undertake a review of the existing abdominal pain and vascular emergencies guidelines. We will look to include additional terminology for clinicians to ensure that they take account of the potential for patients with extensive aortic history not to present with traditional red flag symptoms and to carefully consider whether they should be transported to hospital. We will also advocate the use of the Aortic Dissection Detection risk score during their clinical assessment to aid decision-making around conveyance. Finally, we will also include reference to the potential for ‘Endoleaks’ following an aortic repair. We will follow our existing process for the review and update of our guidance, and this is expected to take around three months. Once complete, the revised guidelines will go for approval at the JRCALC committee, and then for final ratification at 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 trusts, via senior clinicians, are given at least four weeks’ notice of planned updates so that they can prepare for the updates and consider any local education that may be required to support new guidance. If you have any further questions, please do not hesitate to contact me. Yours sincerely Director of Operational Development and Quality Improvement
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