Paul Harries

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

The Chief Executive, University Hospitals Sussex NHS Foundation Trust

1 CORONER

I am Joseph TURNER, Area Coroner for the coroner area of West Sussex,
Brighton and Hove

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

An investigation under s.1 Coroners and Justice Act 2009 was commenced
into the death of Paul Guy Robert Harries in September 2025, on receipt of
an internal Patient Safety Incident Investigation report. (Following his
death at his home address in Brighton on 9th October 2024, his family
contacted the Patient Advice and Liaison Service and Complaints team on
28th February 2025 raising their concerns that Mr Harries had not been
followed up appropriately following the diagnosis of an abdominal aortic
aneurysm [AAA]). The inquest was formally opened on 25th September
2025. I concluded the inquest on 25th February 2026. Further time was
afforded to the family and Hospital Trust to address me on the prevention
of future deaths, without adducing or hearing any new evidence.

4 CIRCUMSTANCES OF THE DEATH

In November 2020 Mr Harries had been diagnosed with an AAA through
screening assessment under the National AAA Screening Programme.
Following a scan on 12th November 2021 he was advised he would be
referred to the Vascular team at the Royal Sussex County Hospital for
additional scanning to obtain more accurate imaging. On 25th November
2021, due to the complexity of the AAA which extended into the iliac
arteries, Mr Harries was referred to the Vascular Assessment Unit to take
over the medical surveillance and scanning of his AAA. Following the
referral to that Unit, a further scan in January 2022 measured an increase
in the aneurysm. Mr Harries did not attend his next scan appointment on
19th July 2022. No further action appears to have been taken, and Mr
Harries was then lost to follow up. He attended the Emergency
Department in February 2023, after a week of coughing up blood; a scan
incidentally showed a further increase in the aneurysm, but this was not
highlighted to the GP and not included in the discharge summary. The GP

Regulation 28 – After Inquest

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 then saw Mr Harries due to high blood pressure in April 2024 and first
became aware of the recent history and results and referred Mr Harries as
‘urgent’ to the Vascular Surgery team. The vascular surgeon operated a
different priority system and rated Mr Harries as ‘amber’ which meant a
triage within 6 weeks and then to be seen within c.40 weeks. A CT scan
on 2nd May 2024 showed the AAA but it was ‘difficult to measure’ and an
outpatient appointment was then booked on 13th September 2024 for 19th
October 2024. However, Mr Harries sadly died from a ruptured AAA before
and whilst awaiting that appointment. Among the issues at the inquest
were what actions should have been taken following the missed VAU scan
on 19th July 2022 to prevent the patient being lost to follow up, and the
sequence of events following the urgent request for review from the GP,
including the ‘recategorising’ of urgency and then long wait for an
outpatient appointment, as well as how the incidental scan findings were
not alerted to the GP.

5 CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving
rise to concern. In my opinion there is a risk that future deaths could occur
unless action is taken.

The rationale for this particular report is that, as paragraph 42 of Chapter
16 of the Chief Coroner’s Guidance for Coroners on the Bench advises -
'where steps have been taken but remain inadequate or incomplete a PFD
report may still be required'.

I also bear in mind that PFD reports are not just required where I perceive
the need to prevent recurrence (which I accept may be practically
impossible) but to reduce the risk of death.

The report is written within that ambit. In those circumstances it is my
statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

Although I accept that a system of audits is now under way, these are
evidently retrospective and the changes made do not appear to fully
resolve the observed weaknesses and risk of differences apparent in the
inquest within the GP-Consultant surgeon-Careflow booking chain whereby
the urgency expressed by the GP does not successfully translate into an
urgent booking, because there remains the risk of manual coding error
and/or that there is no express reason given or reported back to the GP as
to why their patient is or will be afforded the proposed urgency.

Again, although there is current and considerable planned progress on
integration of IT systems, this work is not yet complete and referrals
remain reliant on 3 separate systems which are not yet fully joined up.

Incidental findings from tests conducted in the ED are not always reported

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 to the GP where these may not relate to the presenting complaint. ED
policy appears to remain inconsistent. This is especially important as it
means a Patient with a significant condition, for which they are under their
GP, may have a change in that condition identified at the ED which is not
then always reported back or highlighted urgently to the GP.

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.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by June 15, 2026. 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:

Those members of Mr Harries’ family identified and who participated in the
inquest.

I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may
find it useful or of interest.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. They may send a copy of this report to any person who
they believe 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

Dated: 20/04/2026

Joseph TURNER
Area Coroner for
West Sussex, Brighton and Hove

Regulation 28 – After Inquest

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Responses

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.

HM Area Coroner  
Mr Joseph Turner 
West Sussex, Brighton and Hove 
Parkside Chart Way 
Horsham 
RH12 1XH 

5 June 2026 

University Hospitals Sussex NHS Foundation Trust 
Trust Headquarters 
Royal Sussex County Hospital 
Eastern Road 
Brighton 
BN2 5BE 

Dear Mr Turner 

Inquest into the death of Paul Guy Robert Harries  

Thank you for your letter of 20 April 2026, enclosing your formal report under Regulation 28 
to Prevent Future Deaths. 

My sincere condolences go to Mr 

 family. I am so sorry for their loss. 

Your Regulation 28 report has been shared widely at the Trust to ensure learning and 
senior oversight of the actions we have taken.  

The Lead Consultant for the Emergency Department (ED) at the Royal Sussex County 
Hospital has confirmed that there is now a system in place, introduced in 2026, to review all 
imaging reports obtained in the ED. The ED team check on incidental or relevant unrelated 
findings and ensure that follow-up arrangements are in place and/or the 
informed. In addition, our hospital imaging reports are also available on the electronic 
system which the GPs access and review. 

GP is 

The function of e-RS allows for identification of urgent or routine patients providing referring 
GPs and triaging Consultants use this function accurately and convert referrals from one 
category to another when clinically appropriate. Internally, this has resulted in education for 
the triaging Consultants to ensure that they are aware of the functions of e-RS and are able 
to use it accurately. It has also resulted in regular audits to check the categorisation of 
referrals against the narrative provided by the triaging Consultants.  

We are looking into integrating the electronic systems so that GPs and referring 
Consultants are notified when patients do not attend appointments for investigations or 
imaging arranged for them. This is being developed locally for the Vascular Assessment 
Unit patients with a view to piloting it. For patients with AAA who have met the threshold for 
surgical intervention, we have developed a database to enable us to track the investigation 
and follow-up of all patients. This is reviewed weekly. Mr Harries never met the threshold 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 for treatment and hence would not have been included in this database had it been present 
at the time, but it does serve to protect eligible patients. 

Our Chief Information Officer is supporting this work while the Trust fully implements the 
Trust wide EPR (electronic patient record) system. 

I hope this letter provides you with assurance that the Trust has made significant 
improvements, we are working to continuously improve patient safety and reduce risk.  

Yours sincerely, 

Chief Executive

Track University Hospitals Sussex NHS Foundation Trust

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