UK Inquiry Tracker

Roger Wood

PFD Report Historic (No Identified Response) Ref: 2020-0212

Date of Report 21 October 2020

Coroner Graeme Irvine

Coroner Area East London

Response Deadline ✓ from report 17 December 2020

Community health care and emergency services related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.

View full coroner's concerns

The ultrasound scan of Mr Wood's AAA completed in June 2017 measured the aneurysm as 5.5 ems. The report simply stated the size and position of the AAA. Expert evidence heard by this court confirmed that the nationally accepted, established threshold for intervention in AAAs was when an aneurysm measured 5.5cms (or greater). In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient's GP for assessment. The GP was to decide whether to refer the patient on for treatment. In Mr Wood's case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result. In the light of the sad facts of Mr Wood's death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include advice to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk ofthese tragic circumstances being repeated by directly triggering a referral. My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood's case, is capable of failure.

Sent To

Clinisys UK
Maylands Health Care
Public Health England
Barking, Havering and Redbridge University NHS Trust

Response Status

Linked responses 0 of 4

56-Day Deadline 17 Dec 2020

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Circumstances of the Death

Mr Roger William Wood was diagnosed as suffering from an Abdominal Aortic Aneurysm ("AAA") and since 2005 had been subject to surveillance to monitor that condition. On 5th June 2017 Mr Wood underwent an ultrasound scan that measured the AAA to be 5.5 ems in AP diameter. The measurement was significant, the AAA had grown to a size where the risks presented by the condition outweighed the risk of treatment, accordingly at this point, Mr Wood ought to have been referred for treatment. In 2017 the local procedure in cases of this type was for imaging reports to be sent to the patient's GP, and for the GP to refer the matter to a vascular surgery specialist.

A report of the scan was sent to Mr Wood's GP, Dr, by the hospital sonographer utilising an electronic reporting system Cyberlab. The scan was received by Dr - s surgery, but not acted upon. Mr Wood was not referred to a specialist. The following year, the annual scan measured the AAA to be 5.96 ems in diameter. This time, the results were properly assessed by the GP and a referral was made to vascular surgeons. The referral led to a plan to treat the AAA with an "EVAR" stent. Regrettably, Mr Wood could not undertake this treatment as before the appointed date he sustained a fatal rupture to the AAA on 12/2/19. Expert evidence heard by this court confirmed that had a similar treatment plan been commenced in 2017, it is likely that Mr Wood would have been protected from a future AAA rupture for life.