James Neil COCKBURN · Prevention of Future Deaths report

On 30th May 2023 I commenced an investigation into the death of James Neil COCKBURN. The investigation concluded on the 29th May 2024 and the conclusion was one of Narrative: Died from a myocardial infarction whilst under the care of cardiac specialist teams for assessment for cardiac intervention. The medical cause of death was 1a) Acute myocardial infarction 1b) Coronary artery atheroma 1c) II Diabetes (type 2), Aortic Stenosis, End stage renal disease (on Dialysis), Hypertension, Obesity

James Neil Cockburn had multiple comorbidities. He was referred in August 2022 to cardiology after an echocardiogram indicated he had moderate to severe aortic stenosis of the aortic valve. He had a cardiology appointment on 12th December 2022 and was referred for a trans oesophageal echocardiogram in February 2023. A further echocardiogram on 23rd February at Salford Royal Hospital confirmed severe aortic stenosis that result was entered on the Manchester University Foundation Trust system on 17th March 2023. He was referred to the cardiac surgery team. He saw the cardiac surgeon on 10th May 2023. He was referred for further tests to assess for open heart surgery. Whilst awaiting these tests he had a myocardial infarction and died at his home address on 26th May 2023.

The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.

The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.

In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.