Brian Robert HAVARD · Prevention of Future Deaths report

On 15/01/2018 I commenced an investigation into the death of Brian Robert HAVARD aged 52. The investigation concluded at the end of the inquest on 12/03/2019. The conclusion of the inquest was:

1a Acute Aortic Dissection
1b
1c
II

Mr Havard presented to the Emergency Department (ED) of the NNUH on the evening of 8 January 2019 by ambulance with chest pain and vomiting. He arrived at the hospital but was cared for in the ambulance for several hours by paramedics. Eventually he was admitted just after 6am on 9 January and seen by the junior doctor nearly an hour later. He was discharged with a diagnosis of Musculoskeletal Pain and his partner came to fetch him, he collapsed in the car and an ambulance was called, he died en-route back to the hospital.

1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient.
2. There did not appear to be a system in place for junior doctors who have approached a senior to have their case reviewed with the responsibility for this being on the senior doctor.
3. Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read.