Noel Jones
PFD Report
All Responded
Ref: 2015-0155
All 1 response received
· Deadline: 17 Jun 2015
Coroner's Concerns (AI summary)
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
View full coroner's concerns
being from being have Royal delay
(1) Evidence was given that had Mr Jones been accepted by Worcestershire Royal Hospital earlier he would the balance of probability have survived this episode (2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology (3)
(1) Evidence was given that had Mr Jones been accepted by Worcestershire Royal Hospital earlier he would the balance of probability have survived this episode (2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology (3)
Responses
Action Taken
The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer. (AI summary)
The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer. (AI summary)
View full response
Dear Mr Williams Re: Noel Owen Jones deceased Regulation 28: Report to Prevent Future Deaths am writing with reference to your letter dated 22 April 2015 in which you raised two concerns regarding Trust procedures following evidence which you heard at the inquest into the death of Mr Jones. As a result of your letter confirm that have reviewed the Trust's processes in respect of the following action: Review the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who need to be transferred in from elsewhere_ Attached is my response that sets out in detail the Trust's procedures and the actions which have been taken in response to your concerns: hope that this information provides assurance to you: However; if you require any additional information please do not hesitate to contact me
Sent To
- Worcestershire Acute Hospitals NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
17 Jun 2015
All responses received
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 17th November 2014 commenced an investigation into the death of Noel Owen JONES then aged 77 years The investigation concluded at the end of the inquest on 16 April 2015. The conclusion of the inquest was he died as the result of known complication of necessary surgery the medical cause of death 1(a) Shock; 1(b) haemorrhage left iliac artery and perforated descending colon following cystectomy, 2, atherosclerosis, inhalation of gastric contents, ischaemic heart disease, cancer of the upper rectum irradiation for testicular cancer
Circumstances of the Death
On 2nd October 2014 Mr Jones underwent surgery at the Alexandra hospital. He was later discharged before admitted on two occasions to the Hereford County Hospital: It is clear that upon his admission to Hereford on 15th November 2014 he was severely unwell and had sustained an internal haemorrhage The clinicians at Hereford struggled to Mr Jones admitted to a variety of hospitals including Worcestershire Hospital. Ultimately when Mr Jones appeared to be in extremis Worcestershire Royal Hospital agreed to accept him and he was rushed there by ambulance but died shortly after his arrival: It appears that there was a four hour between the first telephone call to Worcestershire Royal asking for him to be admitted and his ultimate acceptance_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action by reviewing the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who needs to be transferred in from elsewhere_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.