David Birtwistle

PFD Report Historic (No Identified Response) Ref: 2017-0139
Date of Report 18 April 2017
Coroner Terence Moore
Coroner Area Avon
Response Deadline est. 4 September 2017
Coroner's Concerns (AI summary)
A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
View full coroner's concerns
A national review of serious incidents and near misses in similar "front door"
Sent To
  • Brisdoc
  • NHS, University Hospital Bristol NHS Trust
Response Status
Linked responses 0 of 2
56-Day Deadline 4 Sep 2017
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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 30lh November 2016 an investigation commenced into the death of David Lee BIRTWISTLE, Aged 44. The investigation concluded at the end of the inquest on March 2017. The conclusion was that the medical cause of death was I(a) Pulmonary embolism; I(b) vein thrombosis and cardiomyopathy The conclusion as to the death was a narrative conclusion which read: Mr: Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death: This meant that further tests, which have led to an earlier diagnosis of his condition, were not done_
Circumstances of the Death
Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days to his death: This meant that further tests, which could led to an earlier diagnosis of his condition, were not done_ No 111 referral information was available to "front door" or the ED_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action_ 23rd Deep could prior have and
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.