George Leonard Parkes

PFD Report Historic (No Identified Response) Ref: 2013-0252
Date of Report 4 October 2013
Coroner Sarah Ormond-Walshe
Response Deadline est. 23 March 2014
Coroner's Concerns (AI summary)
Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.
View full coroner's concerns
attach the summing up in relation to this case which essentially involves the situation where a patient with an abdominal aortic aneurysm was "lost to follow up"_ The consequences were that it meant that his aneurysm became so big that it ruptured and he died. Potentially, this was a preventable death as if he was eligible, he would have been given the opportunity of having fenestrated endovascular repair which probably have meant he would not have died when he did, It has been suggested to me by witnesses that having a specialist nurse clinic (enabling open monitoring of patients with abdominal aortic aneurysms) and dedicated procedure databaselregister, would prevent this situation happening again. The guidance from the Chief Coroner is that in writing these Reports, the Coroner does not make a very specific recommendation and do not in this case, however; support the Consultant Vascular Surgeons at the Queen Elizabeth Hospital (specifically _ in actions such as the nurse clinic being set up, to prevent future loss of life, and any other measure(s) which will prevent future "lost to follow-up" situations_
Sent To
  • University Hospitals Birmingham NHS Foundation Trust
Response Status
Linked responses 0 of 1
56-Day Deadline 23 Mar 2014
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 4lh January 2013 commenced an investigation into the death of George Leonard Parkes, age 84 The investigation concluded at the end of the inquest on 4lh October 2013. The conclusion of the inquest was: Medical cause of death a
Circumstances of the Death
Please see attached. being
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action: would the do,
Copies Sent To
CASE NUMBER:_0029/2013
Related Inquiry Recommendations

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Pre-1996 Transfusion Testing
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Incomplete GP Patient Data Transfer
New Patient Registration Screening
Infected Blood Inquiry
Incomplete GP Patient Data Transfer
Patient Transfer Protocol
Hyponatraemia Inquiry
Incomplete GP Patient Data Transfer

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.