Noel Owen JONES · Prevention of Future Deaths report

On 17th November 2014 I 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 being 1(a) Shock, 1(b) haemorrhage from 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 .

On 2nd October 2014 Mr Jones underwent surgery at the Alexandra hospital. He was later discharged before being 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 have Mr Jones admitted to a variety of hospitals including Worcestershire Royal 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 delay between the first telephone call to Worcestershire Royal asking for him to be admitted and his ultimate acceptance.

(1) Evidence has given that had Mr Jones been accepted by Worcestershire Royal Hospital earlier he would "on 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)