David Thomas Evans · Prevention of Future Deaths report

On 25 January 2017 I commenced an investigation into the death of David Thomas Evans. The investigation concluded at the end of the inquest on the 20 April 2017. The conclusion of the inquest was a narrative conclusion as follows:

David Thomas Evans died as a result of complications following a ruptured thoraco-abdominal aneurysm.

On 15 January 2017 David Thomas Evans presented at University Hospital Wales Emergency Department with severe abdominal pain. Whilst in hospital he underwent an ultrasound scan of the abdominal aorta that revealed a diameter of 40mm, no further investigation of the aorta was conducted and he was discharged with a diagnosis of diverticulitis and given antibiotics. His abdominal pain persisted and on 22 January 2017 he was admitted to University Hospital Wales. An examination revealed a ruptured aortic aneurysm. Mr Evans underwent emergency surgery that revealed a significant amount of ischaemic bowel from which he was unable to survive. He sadly died later that day.

(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision.
(2) The evidence revealed that records of FAST ultrasound examinations are not routinely stored preventing evaluation of scans to be undertaken after the event.
(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.