Christina Ingrid Smith · Prevention of Future Deaths report

On 27/04/2016 I commenced an investigation into the death of Christina Ingrid Smith, 70 . The investigation concluded at the end of the inquest on 15/02/2017. The conclusion of the inquest was Natural Causes on 31st March 2016 at ████████ Sherborne Mrs Smith died from a naturally occurring haemorrhage. Intrathoracic Haemorrhage Ruptured Dissecting Aortic Aneurysm - Chronic Pulmonary Obstructive Disease

On 30ᵗʰ March 2016 Mrs Smith was referred by her GP to the Emergency Department (ED) of Yeovil District Hospital (YDH). Those assessing Mrs Smith in the ED were not aware of her being under review for a known Abdominal Aneurysm (AA). An ultrasound scan was requested to determine if Mrs Smith had a gallbladder disease.

On 30ᵗʰ March 2016 Mrs Smith returned to YDH when the scan was performed and the results received. By this time those assessing Mrs Smith knew of the AA and were satisfied it had not changed in size. A CT scan was requested. The CT scan was planned for 1ˢᵗ April 2016.
Overnight Mrs Smith deteriorated and died at home. Post Mortem confirmed cause of death as set out above.

(1) A report on Mrs Smith of 2011 identified both an Abdominal Aneurysm and a Thoracic Aneurysm. It appears Mrs Smith was never told of the existence of the Thoracic Aneurysm. It appears Mrs Smith's GP was never told of the existence of the Thoracic Aneurysm.
(2) Only Mrs Smith's Abdominal Aneurysm was placed under surveillance so as to monitor any possible increase in size. Mrs Smith’s Thoracic Aneurysm was not placed under surveillance.
(3) There appears to have been a breakdown in communication with regard to advising both Mrs Smith and her GP as to the existence of the Thoracic Aneurysm.