Recurring concern

Inadequate detection and management of abdominal aortic aneurysms

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First reported 7 Oct 2013•Latest report 17 Apr 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to abdominal aortic aneurysm detection or management, including screening invitation or information, diagnostic consideration, referral pathways, specialist follow-up and escalation of symptomatic or identified aneurysms.

Not included

  • Excludes generic failures in staffing, training, documentation, communication or emergency response unless the report explicitly ties them to abdominal aortic aneurysm detection or management.
  • Excludes unrelated screening programmes, hazards and clinical conditions.
  • Excludes general diagnostic or referral deficiencies that are not specifically concerned with abdominal aortic aneurysms.
Reports
8

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England4
Barking, Havering and Redbridge University Hospitals NHS Trust1
Cardiff & Vale University LHB1
Clinisys Solutions Limited1
Dorset Healthcare University NHS Foundation Trust1
Maylands Health Care1
NHS Pathways1
Public Health England1
Royal College of General Practitioners1
South East Coast Ambulance Service NHS Foundation Trust1
The Society and College of Radiographers1
University Hospitals Birmingham NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Cheshire

    AI-generated summary

    Thomas Geoffrey WAKEFIELD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Wakefield, aged 79, was admitted to hospital on 22 September 2023 after severe stomach pain and sudden collapse at home, and was found deceased in bed the following day. The report identifies concern that abdominal aortic aneurysm and acute pancreatitis can present similarly and may be misidentified, and that guidance did not specifically require exclusion of abdominal aortic aneurysm when pancreatitis was suspected.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of diagnostic guidance to require consideration and exclusion of abdominal aortic aneurysm when diagnosing acute pancreatitis

    Wider context from the report

    “During a review of the NICE guidelines entitled “Abdominal Aortic Aneurysm: diagnosis and management”, and the international guidance, it became apparent that there is a lack of caution within the guidance about the recognised risk that abdominal aortic aneurysm and acute pancreatitis are known to be diagnosed misidentified by clinicians. These conditions can have similar presenting features. Whilst the guidance states that if there is uncertainty about a diagnosis of pancreatitis as not all criteria are met, imaging tests should be undertaken, this does not specifically require the exclusion of abdominal aortic aneurysm which is fatal if untreated. The clinical presentation alongside amylase results in this case met the criteria for a diagnosis of pancreatitis. ”

    Source location

    Thomas Geoffrey WAKEFIELD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review pancreatitis guideline section 1.2 and consider revising wording about raised lipase or amylase levels and alternative conditions.

    Verbatim wording from the response

    “We are therefore going to take the following action:”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the coroner’s concerns about clinical guidance for abdominal aortic aneurysm and acute pancreatitis.

    Verbatim wording from the response

    “Your Report raises the concern that existing clinical guidance does not provide the adequate caution about the recognised risk or diagnoses for abdominal aortic aneurysm (AAA) and acute pancreatitis.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend the pancreatitis guideline to clarify that raised lipase or amylase levels support diagnosis but may occur in other conditions.

    Verbatim wording from the response

    “Further to your regulation 28 report dated 2 May 2024 regarding the very sad death of Thomas Geoffrey Wakefield, I am writing to update on progress taken since our response dated 25 June 2024. In this we committed to amend our guideline for pancreatitis (NG104) from “Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, which are usually raised” to ‘A diagnosis of acute pancreatitis is supported by testing blood lipase or amylase levels, which are usually raised, although raised blood lipase or amylase levels may occur in other conditions’.”

    Source location

    2025 Response from National Institute for Health and Care Excellence
    Page 1 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Guidelines cannot cover all differential diagnoses because each guideline has a defined scope relating to specific medical conditions.

    Verbatim wording from the response

    “It is important to add that NICE guidelines cannot cover all clinical circumstances, and each guideline has a clearly set out and agreed scope. Our guidelines relate to specific medical conditions, and therefore cannot cover all possible differential diagnoses. Responsibility for decisions on the most appropriate treatment stays with individual clinicians, whose role it is to use their professional experience and training to make the correct decision on treatment for each of their patients. NICE guidelines are a practical tool to be used in conjunction with and not as a substitute for clinical judgement.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individual clinicians are responsible for treatment decisions, using professional experience, training and clinical judgement alongside NICE guidelines.

    Verbatim wording from the response

    “It is important to add that NICE guidelines cannot cover all clinical circumstances, and each guideline has a clearly set out and agreed scope. Our guidelines relate to specific medical conditions, and therefore cannot cover all possible differential diagnoses. Responsibility for decisions on the most appropriate treatment stays with individual clinicians, whose role it is to use their professional experience and training to make the correct decision on treatment for each of their patients. NICE guidelines are a practical tool to be used in conjunction with and not as a substitute for clinical judgement.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for relevant clinical guidelines falls outside NHS England’s remit and authority.

    Verbatim wording from the response

    “The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about relevant clinical guidelines should be referred to the organisations responsible for producing them.

    Verbatim wording from the response

    “The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 29 April 2024

    Open published response
  2. East London

    AI-generated summary

    Roger Wood · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roger Wood had been monitored for an abdominal aortic aneurysm, which measured 5.5 cm in June 2017. The scan result was sent to his GP but was not acted upon, and he was not referred for specialist treatment. He later died from a fatal rupture of the aneurysm on 12 February 2019. The principal concern was that the treatment pathway relied on a GP referral link that could fail, allowing vital diagnostic information not to be acted upon.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Reliance on GP assessment and referral within the AAA treatment pathway

    Wider context from the report

    “In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient’s GP for assessment. The GP was to decide whether to refer the patient for treatment. In Mr Wood’s case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result. In the light of the sad facts of Mr Wood’s death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include auto mailed to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral. My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood’s case, is capable of failure. ”

    Source location

    Roger Wood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Brighton and Hove

    AI-generated summary

    John SCOTT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John SCOTT’s death was investigated and the inquest concluded that he died from natural causes. The concerns raised related to emergency call handling, including support for callers who are alone, ambulance estimated arrival times, whether lone callers could re-contact the service if they became unresponsive, and questions about symptoms that might indicate an abdominal aortic aneurysm.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ask patients with abdominal pain about a pulsating mass

    Wider context from the report

    “4. Since we were dealing at this Inquest with a case of previously undiagnosed abdominal aortic aneurysm and since this is not an unusual scenario for Pathways or South East Coast Ambulance to come across, is it not possible to ask the patient whether they can feel anything at the site of the pain e.g., a pulsating mass. This if it is felt, could be a clear diagnostic sign. ”

    Source location

    John SCOTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake a detailed review of additional telephone discriminators for abdominal aortic aneurysm, including risk factors, pain characteristics and organ-dysfunction symptoms.

    Verbatim wording from the response

    “NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

    Source location

    2019-0051-Response-by-NHS-Digital
    Page 5 · response
    Published 2 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Incorporate the resulting abdominal aortic aneurysm triage changes into release 18.

    Verbatim wording from the response

    “NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

    Source location

    2019-0051-Response-by-NHS-Digital
    Page 5 · response
    Published 2 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS Pathways is responsible for setting and changing clinical triage questions, including questions addressing abdominal aortic aneurysm risk.

    Verbatim wording from the response

    “4. All clinical questions that are asked as part of the NHS Pathways triage system are set by the NHS Pathways clinical team and as such, cannot be changed by SECAMb. We understand from ████████ of NHS Pathways that the issue of additional questions to exclude abdominal aortic aneurysm will be part of a review into severe abdominal pain which NHS Pathways already have under way.”

    Source location

    2019-0051-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 2 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Telephone palpation by patients or carers is too difficult and could delay ambulance dispatch for a time-critical condition.

    Verbatim wording from the response

    “Academic studies on abdominal palpation, by trained clinicians, for identifying the presence of AAA have shown not only poor diagnostic accuracy but also wide interobserver variability, affected by the size of both the aneurysm and the patients’ abdomen.”

    Source location

    2019-0051-Response-by-NHS-Digital
    Page 4 · response
    Published 2 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing triage identifies hypovolaemia and critical illness for emergency dispatch, so detecting a pulsatile mass would not necessarily change the disposition.

    Verbatim wording from the response

    “NHS Pathways recognises the serious nature of a ruptured AAA. Within the current triage, symptoms relating to hypovolaemia and critical illness are identified and give rise to an emergency ambulance dispatch. NHS Pathways is currently undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage. These include utilising risk factors like the patient's age together with specific questions to determine the onset and nature of the pain (including its location, nature and severity) and compounding these with symptoms relating to organ dysfunction. The presence of a pulsatile mass, even if it could be reliably identified, would not necessarily change the disposition given the seriousness of the symptoms already identified by the earlier questions.”

    Source location

    2019-0051-Response-by-NHS-Digital
    Page 5 · response
    Published 2 June 2019

    Open published response
  4. Inner North London

    AI-generated summary

    William John Abrahams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William John Abrahams presented to hospital with a ruptured abdominal aortic aneurysm and died there on 28 August 2017 during attempted endovascular repair. The substantive concerns included that he was not invited for aneurysm screening because he was over 65 when the screening programme was introduced, and that the benefits of opting into screening may not be apparent because aneurysms are asymptomatic until they leak.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to invite people over 65 at screening programme introduction for abdominal aortic aneurysm screening

    Wider context from the report

    “(1) Mr Abrahams was not invited for screening to check whether he had an Abdominal Aortic Aneurysm, as he was over 65 at the time that the screening programme was introduced. ”

    Source location

    William John Abrahams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Patients may not appreciate the benefits of opting into screening for asymptomatic abdominal aortic aneurysms

    Wider context from the report

    “(3) As Abdominal Aortic Aneurysms are asymptomatic until they begin to leak, the benefits of “opting in” to the screening programme may not be apparent to patients. ”

    Source location

    William John Abrahams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue supporting London AAA screening providers to improve men’s awareness of screening options.

    Verbatim wording from the response

    “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:”

    Source location

    2018-0074-Response-by-NHS-England
    Page 3 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a local quality standard requiring programmes to record older men’s self-referrals to AAA screening.

    Verbatim wording from the response

    “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:”

    Source location

    2018-0074-Response-by-NHS-England
    Page 3 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver targeted outreach through GPs, health providers, media, community events, patient groups, social media and the programme website to promote AAA screening access.

    Verbatim wording from the response

    “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:”

    Source location

    2018-0074-Response-by-NHS-England
    Page 3 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The UK National Screening Committee determines eligible screening ages and reviews new evidence that might justify changing those recommendations.

    Verbatim wording from the response

    “With regards to point 1, men are currently invited to NHS Abdominal Aortic Aneurysm Screening Programme (“NAAASP”) in the year they are 65. The programme was introduced in England in 2009 on the recommendations of the UK National Screening Committee (“UKNSC”) following review of research evidence and data from existing local screening programmes against specific criteria.¹ This evidence showed a reduction in deaths from aneurysms when men were offered screening in their 65th year. Subsequently the UKNSC concluded that the ultrasound screening should be offered to men in their 65th year with men over 65 being able to self-refer or ‘opt in’ and request screening.²”

    Source location

    2018-0074-Response-by-NHS-England
    Page 1 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing self-referral arrangements and communications are considered sufficient to enable men over 65 to access AAA screening and understand their options.

    Verbatim wording from the response

    “The North East London NAAASP began in April 2013. At this time Mr Abrahams was 81 years and would therefore not have received an invitation to have AAA screening. However he would have received screening had he asked for an appointment.”

    Source location

    2018-0074-Response-by-NHS-England
    Page 2 · response
    Published 16 June 2018

    Open published response
  5. Berkshire

    AI-generated summary

    Mrs Violet Levine Nelson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Violet Nelson collapsed suddenly at home and died on 17 September 2016; a post-mortem examination identified a ruptured thoracic aortic aneurysm. The report raised concerns that earlier ultrasound findings were not overseen by a Consultant Radiologist and did not recommend referral to a Vascular Surgeon or CT examination, and that GPs may not have been aware of the significance of a suprarenal aortic aneurysm.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation

    Wider context from the report

    “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP. (2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon. (3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future. ”

    Source location

    Mrs Violet Levine Nelson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review SCoR and BMUS ultrasound guidelines to add guidance on suspected supra-renal aneurysm referral, imaging, and anatomical assessment.

    Verbatim wording from the response

    “2. We will review the SCoR and BMUS guidelines (2017), specifically to include guidance on referral of suspected supra-renal abdominal aortic aneurysms for thoracic CT, review by a radiologist or a vascular surgeon.”

    Source location

    2017-0356-Response-by-SoR
    Page 3 · response
    Published 11 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate to radiology services the need for clear processes for sonographer onward referral or handling by an authorised colleague.

    Verbatim wording from the response

    “4. We will undertake an exercise to communicate to radiology services the need for sonographers to have clear processes for arranging onward referral or for ensuring this is handled by a suitable colleague in authority.”

    Source location

    2017-0356-Response-by-SoR
    Page 3 · response
    Published 11 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure the NICE lead for the abdominal aortic aneurysm guideline is aware of the Coroner’s concerns.

    Verbatim wording from the response

    “NICE are developing new Clinical Guideline on “Abdominal aortic aneurysm: diagnosis and management”; the expected publication date is November 2018.¹ The guideline is intended for a wide audience, including patients and their families. It will also provide standards and thresholds for clinicians involved in the diagnosis and management of patients with AAs. This appears to be a timely opportunity for NHS England to inform the NICE AAA Committee of the concerns you raised and ask them to consider incorporating appropriate advice to all relevant clinical professions. Therefore, I will ensure that the NICE lead for this Guideline, Mr Andrew Bradbury, is aware of your Regulation 28 letter and the concerns raised by you.”

    Source location

    2017-0356-Response-by-NHS-Engalnd
    Page 2 · response
    Published 11 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local hospital radiology and vascular surgery departments determine referral thresholds for suprarenal aortic aneurysms.

    Verbatim wording from the response

    “Dr Matt Houghton, Medical Director of the Clinical Innovation and Research Centre in the RCGP understands that the cut-offs for referrals for the size of a suprarenal aortic abdominal aneurysm (AAA) after ultrasound is usually determined locally in the hospital between the local radiology department and the local vascular surgeons. It may be worth asking the Royal Berkshire Hospital Reading for their protocol during the time period the ultrasound scans took”

    Source location

    2017-0356-Response-by-RCGP
    Page 1 · response
    Published 11 February 2018

    Open published response
  6. South Wales Central

    AI-generated summary

    David Thomas Evans · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Thomas Evans presented with severe abdominal pain and an ultrasound scan revealed an aortic diameter of 40mm, but no further investigation was conducted and he was discharged. He was later admitted with a ruptured aortic aneurysm, underwent emergency surgery, and died later that day from complications following a ruptured thoraco-abdominal aneurysm. Concerns included inadequate training and supervision for the FAST ultrasound examination, the routine non-retention of scan records, and insufficient escalation of care when a symptomatic patient has an identified abdominal aortic aneurysm.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure appropriate escalation of care for symptomatic patients with FAST-ultrasound-identified AAA

    Wider context from the report

    “(3) The evidence revealed that when an Abdominal Aortic Aneurysm (AAA) is identified in the emergency department by a FAST ultrasound examination and a patient is symptomatic there should always be an appropriate escalation of care. ”

    Source location

    David Thomas Evans · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Exeter and Greater Devon

    AI-generated summary

    Hayden Meirion NORTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform inmates about screening for aortic aneurysm

    Wider context from the report

    “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013, (1) there was no record that his blood pressure was monitored; or (2) that he had been informed of a screening test for aortic aneurysm. He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor. (3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol. There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come. ”

    Source location

    Hayden Meirion NORTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide and track access to abdominal aortic aneurysm screening for eligible Devon prison patients, documenting screening offers, attendance or declining reasons.

    Verbatim wording from the response

    “5.5.1. The Trust now provides a AAA screening programme, which is available to all patients within the Devon prisons. Eligible patients (as defined by the National AAA Screening programme) are tracked to ensure all are offered and receive screening, or reasons for declining are clearly documented.”

    Source location

    2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
    Page 3 · response
    Published 13 April 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote national screening programmes through monthly health-promotion sessions and prison-wide posters.

    Verbatim wording from the response

    “5.5.3. The AAA screening is actively promoted in the prison, as noted in recent audit where of the 29 patients who attended for AAA screening, 18 were self-referrals. (See appendix 5)”

    Source location

    2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
    Page 4 · response
    Published 13 April 2015

    Open published response
  8. Birmingham and Solihull

    AI-generated summary

    George Leonard Parkes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    George Leonard Parkes, aged 84, died during surgery for a ruptured abdominal aortic aneurysm. The report describes him as having been lost to follow-up, allowing the aneurysm to become very large before rupture, and identifies concerns about monitoring and follow-up arrangements for patients with abdominal aortic aneurysms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain follow-up of patients with abdominal aortic aneurysms

    Wider context from the report

    “I 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 would have meant he would not have died when he did. It has been suggested to me by the witnesses that having a specialist nurse clinic (enabling open monitoring of patients with abdominal aortic aneurysms) and dedicated procedure database/register, 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 I do not in this case. I do, 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. ”

    Source location

    George Leonard Parkes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026