Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0291, written 3 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2026 |
|---|---|
| Reference | 2026-0291 |
| Deceased | John Keen |
| Coroner | Nicholas Lane |
| Coroner area | Devon, Plymouth and Torbay |
| Organisation named | South Western Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
COUNTY OF DEVON, PLYMOUTH AND TORBAY
CORONER AREA
REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 OF THE CORONERS
(INVESTIGATION) REGULATIONS 2013
JOHN SOUTHAM KEEN
HM AREA CORONER
NICHOLAS LANE
REGULATION 28 – REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1) Chief Executive
- South Western Ambulance Service NHS Trust (SWAST NHS)
2) Chair
- JRCALC liaison committee, Association of Ambulance Chief Executives (JRCALC)
1.
CORONER
I am Nicholas Lane – HM Area Coroner for County of Devon, Plymouth and Torbay.
2.
DATE OF REPORT
3 June 2026.
3.
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.
4.
THIS REPORT IS BEING SENT TO:
1) South Western Ambulance Service NHS Foundation Trust (SWAST NHS);
2) JRCALC liaison committee, Association of Ambulance Chief Executives (JRCALC).
You are under a duty to respond to this report within 56 days of the date of this report – 29 July 2026.
I may extend the required date for response, if an appropriate application is made by you.
5.
YOUR RESPONSE
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.
I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s PFD Publication Policy (2026), you should send any representations
that you wish to make regarding publication of your response. These representations should be made at
the same time as the response is provided. I will pass any representations received to the Chief Coroner
for their determination.
Please note any links to webpages included in the response will not be checked for sensitive information
prior to publication, as the information is already online.
The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s
webpage – Non-responses to Prevention of Future Deaths (PFD) reports – Courts and Tribunals Judiciary.
6.
BRIEF OVERVIEW OF CONCERNS
I am concerned about the process of internal investigation, and associated lack of learning, by SWAST NHS
– in that the clinical review carried out by them did not appreciate or understand Mr Keen’s relevant
background medical history (despite this clearly being given to both call handlers and clinicians from
SWAST NHS) and it did not properly take into account the full picture that should have been known to
SWAST NHS clinicians when they attended on Mr Keen at his home on 19 August 2023; namely, that Mr
Keen had a known thoracic ascending aortic aneurysm and was displaying symptoms suggestive of possible
aortic dissection.
Separately, I am concerned that the JRCALC guideline that is in place nationally, in respect of paramedic
clinicians considering aortic dissections (JRCALC vascular emergencies guideline) is confusing, potentially
contradictory and not easy to navigate for clinicians working under pressure.
7.
ACTION SHOULD BE TAKEN
In my opinion, unless action is taken to address the above concerns then there is a significant risk of future
deaths and I believe that your organisation has the power to take such action.
8.
INVESTIGATION and INQUEST
On 5 September 2023 an investigation was commenced into the death of John Southam Keen. The
investigation concluded at the end of the inquest hearing on 13 May 2026 at Exeter Coroner’s Court, heard
by HM Area Coroner Nicholas Lane.
Section 2 of the Record of Inquest (which recorded the medical cause of Mr Keen’s death) was determined
as:
1a) hypoxic brain injury
1b) type A ascending aortic dissection (operated 19/08/2023)
2) hypertension
Section 3 of the Record of Inquest (which set out how, when and where Mr Keen came by his death) was
determined as:
‘John Keen had been diagnosed with a thoracic ascending aortic aneurysm in 2018, which was being
managed and monitored by cardiology professionals. John suffered a dissection of this aneurysm at home
in the morning on 19 August 2023, with symptoms of sudden onset chest pain radiating to his back and
neck. Paramedics attended on John and considered that he was likely suffering symptoms of acute
coronary syndrome. Paramedics were informed that John had an ascending aortic aneurysm; however, for
reasons unknown, they based their clinical assessment on John having an abdominal aneurysm. If
consideration had been given by attending paramedics to both John’s presenting symptoms and accurate
clinical history then he would have required urgent transfer to the arterial surgery specialist unit, where he
would have undergone emergency surgery. Instead, John only arrived at this unit, Derriford Hospital,
Plymouth, a number of hours later, as he was initially taken for assessment at Torbay Hospital, where
imaging confirmed the dissection. John suffered a cardiac arrest prior to surgery being undertaken at
Derriford Hospital, Plymouth in the afternoon on 19 August 2023. Although surgery was undertaken
successfully, John had suffered a fatal hypoxic brain injury as a result of his cardiac arrest. John’s life
support was withdrawn and he died at Derriford Hospital on 24 August 2023.’
Section 4 of the Record of Inquest (which set out conclusions in respect of Mr Keen’s death) was
determined, in narrative form, as:
‘John Keen died from the progression of a natural disease process, contributed to by delayed transfer to
specialist surgical unit and consequential delay in undergoing emergency surgery. John’s death was
contributed to by neglect.’
9.
CIRCUMSTANCES OF DEATH
Mr Keen was a 70 year old man who had significant vascular disease - he had been diagnosed with
hypertension a number of years previously and in 2018 he was diagnosed as having a thoracic ascending
aortic aneurysm. The size of this aneurysm was monitored in the community and was felt to be fairly static
and stable from diagnosis through to the summer of 2023.
Mr Keen suddenly became unwell in the morning at home on 19 August 2023. He initially reported
difficulty breathing, with sudden onset chest pain which had radiated to his back and neck. Mr Keen’s wife
called 999 and spoke with the ambulance control, informing them that he was suffering from chest pain
and that he had a diagnosis of an ascending aortic aneurysm.
Paramedics attended Mr Keen’s home and assessed him – they were informed that he had an ascending
aortic aneurysm (both orally by Mr Keen’s wife and they were shown recent clinic documentation from
the cardiology service confirming this history) and noted his clinical presentation. Paramedics considered
it likely that John Keen was suffering with acute coronary syndrome and took him to the nearest acute
hospital. Paramedics incorrectly recorded, on their patient record documentation, that Mr Keen had a
triple AAA (abdominal aortic aneurysm), rather than an ascending aortic aneurysm.
Mr Keen was assessed by a consultant in emergency medicine at hospital and, having been informed of his
background medical history (including an ascending aortic aneurysm) and noting his clinical presentation
that day, they suspected an aortic dissection. This was confirmed on imaging and Mr Keen was then
transferred to the regional tertiary arterial centre for emergency surgery.
Surgery took place later on in the afternoon on 19 August; however, immediately prior to this Mr Keen
went into cardiac arrest – prior to him being able to be placed on life support machine in theatre he
received cardio-pulmonary resuscitation (CPR) and, during this time, had no cardiac output for around 20
minutes. Although surgery to repair the aortic dissection was carried out successfully, Mr Keen had
suffered a fatal hypoxic brain injury whilst in cardiac arrest, and, following prognostic discussions with
family members, active care was withdrawn and he died on 24 August 2023.
10.
DETAIL OF CONCERNS
During the course of the investigation and inquest I obtained and heard evidence giving rise to concerns.
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.
The MATTERS OF CONCERN are as follows:
SWAST NHS
1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST
NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS, with concerning
circumstances surrounding the care provided by attending paramedics not being identified and analysed
properly – therefore whether there were any appropriate recommendations to inform future care
provision were not considered by SWAST NHS.
All clinical witnesses who gave evidence at the inquest (with the exception of the author of SWAST NHS’s
clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm
with him presenting with sudden onset chest pain radiating to his back, should have alerted attending
paramedics to the real possibility of an aortic dissection. Given this and the gravity of this potential
situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial
centre by emergency ambulance transfer. If this had happened, Mr Keen would have undergone life-saving
cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial
investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic
aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider
how this error may have occurred. The clinical review went on to conclude that Mr Keen was not
demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at
the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and,
even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic
aneurysm) together with his presenting symptoms of sudden onset radiating chest pain, SWAST NHS did
not consider that an aortic dissection was a potential differential diagnosis that needed urgent
investigation.
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of
whom considered that Mr Keen’s presentation and known medical history should have resulted in there
being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is
also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital,
and who considered his known history and his presenting symptoms on that day, held such suspicion and
immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding
of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly,
that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic
dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background
together with any concerns in relation to clinical care provided by their clinicians, and do not take steps to
try and learn from these incidents when they occur, then there is an obvious, significant and continuing
risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC)
clinical guidelines does not lie with SWAST NHS (it lies with this named committee, which is part of the
AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see
below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their
views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention
of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond
with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS
confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline
(which had last been updated in July 2025) and that the substantive provisions in respect of clinicians
considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including
myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was
confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns
were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes
apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a
separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and
descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these
sections are confusing and it is not easily apparent which one should be considered in respect of each
different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly
location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing
conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then
a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the
three columns – however, there is then no information about what should happen given any particular
score or how the total score should affect a clinician’s impression of clinical risk. This appears to be
unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the
guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’.
Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’.
It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is
concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was
confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others.
Further, it was mentioned that this guidance compares unfavourably to other documents used in similar
clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the
inquest heard was used in some emergency departments in the UK and sets out, on one page, what the
concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and
how these should then inform the urgency of the clinical response.
JRCALC
1)
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS
confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline
(which had last been updated in July 2025) and that the substantive provisions in respect of clinicians
considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including
myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was
confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns
were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes
apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a
separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and
descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these
sections are confusing and it is not easily apparent which one should be considered in respect of each
different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly
location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing
conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then
a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the
three columns – however, there is then no information about what should happen given any particular
score or how the total score should affect a clinician’s impression of clinical risk. This appears to be
unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the
guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’.
Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’.
It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is
concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was
confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others.
Further, it was mentioned that this guidance compares unfavourably to other documents used in similar
clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the
inquest heard was used in some emergency departments in the UK and sets out, on one page, what the
concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and
how these should then inform the urgency of the clinical response.
11.
COPIES AND PUBLICATION OF THIS REPORT
I have a duty to send a copy of my report to every Interested Person (IP) who in my opinion should receive
it.
I also may send a copy of the report to any other person who I believe may find it useful or of interest.
I confirm I have sent the report to:
1) Legal representatives of John Keen’s family (IP).
2) Torbay and South Devon NHS Foundation Trust (IP).
3) Royal Devon University Healthcare NHS Foundation Trust (IP).
4) University Hospitals Plymouth NHS Trust (not an IP, but were involved in care provision).
I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication of the contents of this report in
line with the Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief
Coroner alongside the report. Please refer to Section 5 above for additional information relating to the
publication of reports and responses.
12.
Date: 3 June 2026
Signature:
Nicholas Lane
HM Area Coroner
County of Devon, Plymouth and Torbay
2 responses 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.
8 July 2026 Association of Ambulance Chief Executives 25 Farringdon Street London EC4A 4AB Mr N Lane HM Area Coroner for County of Devon, Plymouth and Torbay Dear Mr Lane JOHN SOUTHAM KEEN (DECEASED) I am writing in response to the preventing future deaths report in my capacity as managing director of the Association of Ambulance Chief Executives (AACE). On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Keen. 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 assists with the implementation of nationally agreed policy. Our primary focus is the ongoing development of UK NHS 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 chairs along with a network of national specialist groups. We respond in relation to your proposed matters of concern: Vascular emergencies guideline has been considered to be confusing, potentially contradictory and not at all user-friendly for paramedics. The JRCALC guidelines are advisory and have been developed to assist paramedics working in UK ambulance services in making decisions about the management of patients’ health, including treatments and to support clinical practice. 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. Your matter of concern was brought to the attention of JRCALC, and specifically to the clinical leads for the vascular emergencies guideline. These clinical leads are our expert advisors who have a background of vascular and surgical knowledge and have offered to support this work. They= are currently reviewing the sections of guidance that relate to aortic aneurysms and aortic dissections. As part of this process of review, we will ensure paramedic input so the guidance is as user friendly as possible. We had an initial meeting on the 22 June 2026 to discuss your concerns which I have summarised below. 1. Section titled ‘aortic aneurysms’ This section will be fully revised and updated aiming to remove any confusion and add clarity. 2. The ‘aortic dissection detection risk score’ The detection risk score table was included in a revision of the guideline in 2024. We aimed to assist in identifying the more subtle signs of vascular emergencies that may be missed. As this clinical risk stratification tool is not specifically designed for pre-hospital use, and only validated for hospital assessment, calculating a risk score would lead to actions that cannot be undertaken in the pre- hospital setting, for example D-dimer testing. The tool was modified so that if any score was positive in any column, it was recommended that the patient should be conveyed to hospital. We recognise this information may be improved with updated formatting of the table. 3. Hypotension as a risk factor The review group will amend the wording to make the relevance of high and low blood pressure clearer. 4. used in similar clinical situations This guidance unhelpfully long-winded & compares unfavourably to other documents On initial review of the guideline, we agree with this assessment. Our specialist advisors have recommended we update the section on ‘aortic aneurysms’. We are considering developing a new algorithm to streamline key information and actions for clinicians. Our intent is to complete our review and subsequent update of the vascular emergencies guidance. The revised guideline will be presented to JRCALC for approval, and then for final ratification by 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 services are given at least four weeks’ notice of planned updates via senior clinicians so that they can prepare accordingly and consider any local education that may be required to support new guidance. I hope this is helpful. Please do not hesitate to contact me should you require any further information. Yours sincerely Managing Director
Mr Nicholas Lane HM Area Coroner for the County of Devon, Plymouth and Torbay Trust Headquarters Abbey Court Eagle Way Exeter Devon EX2 7HY 14 July 2026 Dear Mr Lane Prevention of Future Deaths Report following the inquest touching the death of Mr John Southam Keen I am writing on behalf of South Western Ambulance Service NHS Foundation Trust (thereafter referred to as the Trust) in response to a Regulation 28 report to prevent future deaths, issued in relation to death of Mr John Southam Keen. I am the Trust’s Executive Medical Director, a Consultant in Anaesthesia and Intensive Care Medicine for United Hospitals Bristol and Weston NHS Foundation Trust, and a Helicopter Emergency Medical Service (HEMS) doctor for Great Western Air Ambulance. I additionally sit as Co-Chair of JRCALC. I would firstly like to extend my personal condolences to the family of Mr Keen at what must still be an extremely difficult time. In your Regulation 28 report, the principle concerns you identified were in relation to the Trust investigation and subsequent report, and cogency of the national JRCALC clinical guidelines for Vascular Emergencies. I will address these in turn: Quality of the Internal Clinical Review Over the past three years, the Trust has worked diligently to improve both the timeliness and quality of its investigations in extremely challenging circumstances. We are proud of the progress our teams have made in strengthening this aspect of our clinical governance processes. However, we offer a sincere apology that the investigation undertaken in relation to the review of care afforded to Mr Keen on 19 August 2023 contained inadequacies and inconsistencies. While this does not excuse the shortcomings, it is recognised that aneurysms, in their various forms, represent a complex clinical area in which terminology and assessment can be challenging and, at times, lead to confusion. In response to the feedback received, we have undertaken a review of our processes. While this has not identified the need for immediate structural changes, we will continue to strengthen clinical oversight and scrutiny of investigation reports to minimise the risk of similar issues occurring in the future. Clinical Decision-Making and Differential Diagnosis As discussed at the inquest, the diagnosis of aneurysms cannot be made on symptoms alone in the pre-hospital setting by ambulance clinicians and requires access to diagnostic equipment. A further independent review of the clinical care was undertaken by one of our Consultant Paramedics. This review reaffirmed the views of those who gave evidence at inquest that many presenting symptoms overlap across conditions. In this case, the attending crew applied their clinical judgement and assessed that the most likely diagnosis was a Non-ST Elevation Myocardial Infarction (NSTEMI), which informed their decision to convey the patient to Torbay Hospital. Learning and Governance The Trust recognises that vascular emergencies are complex and can be difficult for clinicians to identify accurately. This is an area in which the Trust has been actively engaged for several years. Our work has included supporting the development of JRCALC and AACE guideline reviews completed in 2025. In addition, the Trust has engaged with initiatives such as Think Aorta, to explore further opportunities to raise awareness and support clinical decision -making in this area. We acknowledge that the recognition of aneurysms will remain inherently challenging due to overlapping clinical presentations. The Medical Director and Deputy Director of Clinical Care recognise that, despite best efforts, diagnostic uncertainty will persi st in some cases. Nevertheless, the Trust remains committed to supporting clinicians with the most up-to- date evidence and guidance available. Vascular Emergencies Guidance Following a further review after the inquest, the Trust has added an additional information box at the top of the JRCALC national vascular guideline. The box provides a clear list of the vascular centres across the South West and the hospitals which feed into them. This information is not included in national JRCALC guidance, as it is region -specific. It is acknowledged that any guideline covering the recognition of aneurysms faces the inherent challenge posed by both atypical and overlapping symptoms. In such situations, ambulance clinicians rely on their professional judgement to determine the most appropriate clinical pathway. The Trust introduced improved remote clinician support for ambulance clinicians during 2025. A single clinical telephone number provides rapid access to advice from a range of senior clinicians. In the case of aneurysm, a Specialist Paramedic in Critical Care would be most appropriate. Working as part of the Critical Care, function, they support circa 460 calls per month. Engagement with JRCALC and AACE The Trust maintains strong relationships with AACE and continues to contribute regularly to the development of JRCALC guidance through the National Ambulance Service Medical Directors Group and the National Lead Paramedic Group. In response to the inquest, a senior member of the Trust met with the Clinical Support Managers for AACE on 17 June 2026 to review the national vascular guideline against findings. During this discussion, AACE identified potential improvements to the language used within the clinical guidance to enhance clarity, particularly around the use of the acronym ‘AAA’. We are also aware that JRCALC are updating the Vascular guidance in line with the recommendations. The Trust is supportive of these proposed changes and will continue to engage proactively in their development. I sincerely hope the above addresses the concerns raised. Yours sincerely Executive Medical Director
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