John Lee developed an abdominal aortic aneurysm which had become enlarged. His GP wrote an urgent referral letter to the appropriate hospital specialist department requesting a vascular assessment. That letter was considered the next day by a specialist nurse at Medway Maritime Hospital, who after conferring with a consultant vascular surgeon graded the referral as urgent, endorsed the GP letter with the words “next vascular slot Maidstone” and passed that letter to a clerk or secretary to fix the appointment. The nurse’s evidence was that the Trust had a policy to see such patients within 2 weeks, that vascular clinics were conducted on a Monday and that therefore her intention had been that Mr Lee would be seen on the subsequent Monday. If that had been the “next” Monday, the appointment would have been within 5 days of grading. Due to a clerical error which was admitted but not explained, the secretary allocated Mr Lee to an appointment 5 weeks later than the “next” Monday. When Mr Lee attended that appointment, his aneurysm had become tender and the consultant admitted him for an emergency procedure. The next day Mr Lee died on the operating table, as a consequence of uncontrollable haemorrhaging and ventricular tachycardia, following otherwise successful reduction of the aneurysm and insertion of Dacron graft. Expert opinion was accepted to the effect that if Mr Lee had been seen within 2 weeks of referral as intended, he could have been managed as an elective procedure, allowing for early stopping of his Clopidogrel medication, better precautionary control of a cardiac arrythmia and a less acute situation.

(1) The use of the expression “next vascular slot” is uncertain and open to mis-interpretation (2) There should be provision for the direct input of clinical grade staff in setting clinical especially urgent appointments (3) There should be consideration given to a checking procedure to guard against human error or misunderstanding of priority