Brian Havard
PFD Report
Historic (No Identified Response)
Ref: 2019-0101
Coroner's Concerns (AI summary)
Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate system for junior doctor case review by seniors were identified.
View full coroner's concerns
The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient: These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew: He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice: The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG: He evinced no professional curiosity about a him, patient needing three doses of morphine and being considered for discharge: The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records: He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes: He did not give a convincing explanation for not reviewing the patient There did not appear to be a system in place for junior doctors who have approached a senior to have their case reviewed with the responsibility for this being on the senior doctor_ Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read:
Sent To
- Norfolk and Norwich University Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
6 Aug 2019
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
Investigation and Inquest
On 15/01/2018 commenced an investigation into the death of Brian Robert HAVARD aged 52. The investigation concluded at the end of the inquest on 12/03/2019. The conclusion of the inquest was: 1a Acute Aortic Dissection 1b lc
Circumstances of the Death
Mr Havard presented to the Emergency Department (ED) of the NNUH on the evening of 8 January 2019 by ambulance with chest pain and vomiting: He arrived at the hospital but was cared for in the ambulance for several hours by paramedics: Eventually he was admitted just after 6am on 9 January and seen by the junior doctor nearly an hour later. He was discharged with a diagnosis of Musculoskeletal Pain and his partner came to fetch he collapsed in the car and an ambulance was called he died en-route back to the hospital:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you (and/or your organisation) have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.