Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0514, written 14 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2025 |
|---|---|
| Reference | 2025-0514 |
| Deceased | David Jones |
| Coroner | Nathanael Hartley |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottingham University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Nottingham University Hospitals NHS Trust (“the Trust”). 1 CORONER I am Nathanael Hartley, Assistant Coroner for the coroner area of Nottingham and Nottinghamshire. 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 12 August 2024 an inquest was opened into the death of David Charles Noel Jones, aged 65. The inquest concluded on 2 September 2025. I made a narrative determination at inquest that he died as a result of an aortic dissection. 4 CIRCUMSTANCES OF THE DEATH Mr Jones had attended hospital following an episode of dizziness. He was reviewed in the Emergency Department and noted to have low blood pressure and a low pulse rate. He was monitored within Resus before being stepped down to Majors whilst awaiting admission to ward B3 for monitoring of his blood pressure and kidney function. Mr Jones had an incident of chest pain and sweatiness whilst mobilising when he was in Majors. That was not brought to the attention of a senior doctor and did not result in a further clinical assessment and consideration of further investigations within resus. Those likely further investigations may well have revealed the presence of an aortic dissection. Mr Jones remained as an inpatient in hospital until the following day when he was discharged and sadly died later that day from the effects of the aortic dissection. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. This is not the first inquest involving the Trust where there have been concerns about an undiagnosed aortic dissection. I am personally aware of another recent inquest in which evidence was provided to assure the coroner that relevant learning has been disseminated across the appropriate departments at the Trust, and processes amended to try to prevent recurrence. I am also aware of evidence given to my coroner 1 colleagues about the Trust’s educational programme, particularly for the emergency department team. The MATTERS OF CONCERN are as follows. – 1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department, despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments. 2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change. I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 December, 2025. 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: 1. Mr Jones’ family. I have also sent a copy to the Chair of the NHS Nottingham and Nottinghamshire Integrated Care Board, for their information. 9 Dated: 14 October 2025 Nathanael Hartley HM Assistant Coroner For Nottingham and Nottinghamshire 2
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.
9 December 2025 STRICTLY CONFIDENTIAL Miss Mairin Casey HM Coroner for Nottingham and Nottinghamshire The Council House Nottingham NG1 2DT Medical Directors Office 3rd Floor, Trust Headquarters City Campus Hucknall Road Nottingham NG5 1PB www.nuh.nhs.uk Dear Miss Casey Please find enclosed Nottingham University Hospitals NHS Trust’s (NUH) response to the Regulation 28 Prevention of Future Deaths Notice issued by Assistant Coroner, Nathaniel Hartley, on 2 September 2025, following inquest into the death of the late Mr David Charles Noel Jones. This response describes a program of work at NUH with workstreams supporting the improvement of early diagnosis of Acute Aortic Dissection. Here we summarise the completed, ongoing and planned future work within NUH to improve the early detection of Acute Aortic Dissection; the Acute Aortic Dissection Improvement project. This work will be undertaken by an Acute Aortic Dissection Improvement Group led by the Cardiac Surgery team, with support from colleagues in the Emergency Department, Acute Medicine, Stroke, Radiology, Patient Safety team and the Medical Director’s Office, and involves other teams such as Stroke and Radiology etc as required. The Acute Aortic Dissection Diagnosis improvement work is in liaison with the colleagues from across the East Midlands Aortic Network to ensure inclusion of best practice and learning from other regional centres across the network and National Programmes. We would like to extend our apologies and condolences to the family and friends of the late David Charles Noel Jones and hope this response provides assurance of our commitment to improving patient safety and experience. Yours sincerely Medical Director and Responsible Officer Enc
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