Kevin John Gilbert · Prevention of Future Deaths report

On 5th February I commenced an Investigation into the death of Kevin John Gilbert. The Investigation concluded at the end of the Inquest on 2nd December 2015. The conclusion of the Inquest was that Kevin John Gilbert died as a result of natural causes.

Mr Gilbert suffered an aortic root dissection in the morning of 29.01.15 which was diagnosed provisionally on his symptoms and then by confirmatory aortagram soon after arrival at the Accident and Emergency Department at William Harvey Hospital by ████████ Consultant in Accident and Emergency Medicine. Mr Gilbert was stabilised and considered to be a suitable patient for transfer to St Thomas’ Hospital for repair of the dissection because of his age (49 years) and lack of relevant previous medical history (mild asthma only). ████████ spoke to ████████ on call SpR in Cardiothoracic surgery at St Thomas’ Hospital at just after 12.45pm who advised that he would need to see the radiology images before he could accept Mr Gilbert as a patient. ████████ had already asked the Radiology Department to send them to St Thomas’ Hospital but it wasn’t until 3.40pm that Dr Cummings confirmed to ████████ that he had received them and that Mr Gilbert could be transferred. During the previous 3 hours, ████████ called Mr Cummings several times to stress the urgency of the situation and the critical condition of his patient. At one point, he sought to escalate his request and asked to speak to Mr Cummings’ Consultant, Mr Avlonitis, to be told that he was in surgery and unavailable.

Mr Gilbert left William Harvey Hospital shortly after 3.40pm in an ambulance for the road journey to St Thomas’ Hospital. At 3.54pm he returned to William Harvey Hospital as he had arrested shortly after departure. All attempts were made to resuscitate him including pericardiocentesis and resuscitative thoracotomy but without success. His death was confirmed at 4.25pm.

The cause of Mr Gilbert’s death was:-

1a Acute haemopericardium

1b Aortic dissection.

• There appeared to be confusion on the part of ████████ as to the standing protocols at St Thomas’ Hospital concerning transfer of patients with a diagnosis of aortic dissection.

• Given that Mr Gilbert was presenting at William Harvey Hospital as an acute emergency requiring specialist surgery at a tertiary centre and that his diagnosis of suspicion made on presenting clinical symptoms by a Consultant in Accident and Emergency medicine which was confirmed by CT scan, it was not reasonable for ████████ to rely on his understanding of the procedure of accepting such patients and wait for the CT imagery before agreeing that he could be transferred.

• It was not reasonable to decline ████████ request for the decision to accept Mr Gilbert to be escalated to a Consultant on the basis that ████████ was in theatre and unable to talk to ████████

• I heard evidence from my independent expert in Cardiothoracic Surgery, ████████ that had Mr Gilbert been transferred to St Thomas’ Hospital without delay he may have been in a position to undergo lifesaving surgery. Whilst his blood pressure was low during the 3 hour wait, he was self-ventilating and did not arrest until shortly after 3.40pm. Had he arrested at St Thomas’ Hospital, the facilities there to perform emergency surgery were more specialist and suitable than at William Harvey Hospital. Mr Gilbert’s chances of survival would have been greater had the delay in accepting him for transfer been avoided.