David Evans
PFD Report
Historic (No Identified Response)
Ref: 2017-0134
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
16 Jun 2017
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision: (2) The evidence_revealed that records of FAST_ultrasound examinations are not_ and and routinely stored preventing evaluation of scans f0 be undertaken aiter the event The evidence revealed that where an Abdlominal Aortic Aneurysm (AAA) is iclentified in the emergercy department by a FAST ultrasound examination and patient is symptomatic there should always be an appropriate escalation of care
Action Should Be Taken
(0) Consideration should be given ko reviewing your procedures related t0 the training and the supervision Of those undergoing training in conducting FAST Ultrasound examinations (2) Consideration should be given to reviewing your procedures for recording the outcome 0f FAST ultrasound examinations_ (3) Consideration should be given to reviewing your procedures surrounding the management Of symptomatic patients where an AAA has been identified by a FAST ultrasound examination: In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
Report Sections
Investigation and Inquest
On 25 January 2017 | commenced an investigation into the death of David Thomas Evans. The investigation concluded at the end of the inquest on the 20 April 2017. The conclusion of the inquest was a narrative conclusion as follows: David Thomas Evans died as a result of complications following a ruptured thoraco-abdominal aneurysm.
Circumstances of the Death
On 15 January 2017 David Thomas Evans presented at University Hospital Wales Emergency Department with severe abdominal pain: Whilst in hospital he underwent an ultrasound scan of the abdominal aorta that revealed a diameter 0f 4Omm; no further investigation of the aorta was conducted he was discharged with a diagnosis of diverticulitis and given antibiotics His abdominal pain persisted and on 22 January 2017 he was admitted to University Hospital Wales_ An examination revealed a ruptured aortic aneurysm: Mr Evans underwent emergency surgery that revealed a significant amount of ischaemic bowel from which he was unable to survive_ He sadly died later that day_
Inquest Conclusion
David Thomas Evans died as a result of complications following a ruptured thoraco-abdominal aneurysm.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.