Thomas Geoffrey WAKEFIELD · Prevention of Future Deaths report

On 02 January 2024 I commenced an investigation into the death of Thomas Geoffrey WAKEFIELD aged 79. The investigation concluded at the end of the inquest on 10 April 2024. The conclusion of the inquest was that:

Thomas Wakefield died from natural causes. It is not possible to say on balance of probabilities whether Mr Wakefield would have survived if the correct diagnosis had been made on admission.

On 22 September 2023, 79 year old Thomas Wakefield was admitted to Countess of Chester Hospital at 22:22 hours with a three day history of severe stomach pain and sudden collapse at home in the early afternoon. The clinicians were not made aware of the collapse at home.

He was promptly assessed in A&E for concerns with acute kidney injury. The plan was to prescribe intravenous fluids due to hypotension. There was a delay in medical assessment. A CT scan was considered at 05:59 but not ordered or completed. This was a missed opportunity to review the diagnosis of pancreatitis on admission and provide a 50% chance of survival.

He was sadly found deceased in bed at 16:10 hours on 23 September 2023.

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.