On the 5th July 2017 I commenced an investigation into the death of Mrs Pamela Sunter (aged 69). The investigation concluded at the end of the inquest on 14th February 2019. The narrative conclusion of the inquest was that: Mrs Sunter died on the 1st July 2017 in the Northern General Hospital,  Sheffield.  It is likely that since May she had been developing a rare infection  which progressed eventually to two abdominal aortic aneurysms arising from  an aortitis.  Whilst it is recognised that this condition is exceedingly rare and  that reaching a diagnosis earlier would have bene immensely difficult, there  was an opportunity lost to progress the matter when cultures were not taken  from Mrs Sunter at an early stage of her admission to the hospital at Barnsley  on the 14th June 2017.  However, it cannot be said that different actions  would more likely than not have saved Mrs Sunter’s life. 

The issue of this Regulation 28 Report does not relate to the matters recorded in the narrative conclusion but rather to a possible issue of confusion between an urgent referral for an ultrasound scan and a referral for a two week wait consultant appointment.

The circumstances so far as relevant to this Regulation 28 report are as follows. A General Practitioner saw Mrs Sunter on the 26th May 2017. The complaint was of low back pain for some weeks, significant weight loss and a bloated/tender abdomen. The doctor arranged for blood tests and an urgent direct access ultrasound. There seemed to be much confusion around this point but the inquest clarified the situation. This was a referral to have the scan done promptly, not to see a clinician. Had the scan revealed a need, then a further two week referral to a clinician would have been required.

Discussion subsequent to the inquest has indicated that the potential source of confusion for two week wait forms in this case has very likely been overtaken by the provision of redeveloped forms already. However, I have learnt that whilst it is relatively easy to place new forms on a system it is apparently much more difficult to remove old forms which can sometimes lead to a confusion. Further confusion could obviously endanger the life of a patient.