Peter STAJIC · Prevention of Future Deaths report

On 21 March 2022 I commenced an investigation into the death of Peter STAJIC aged 60. The investigation concluded at the end of the inquest on 01 February 2024. The conclusion of the inquest was that: He died from a complication following a medical procedure to which a missed opportunity to provide medical intervention contributed.

Peter was pronounced dead at 04.50 on 27 February 2022 at Calderdale Royal Hospital, Halifax. He was aged 60, fit and well save that he had required a corotid endarterectomy - undertaken on 12 January 2022. Due to a post operative haematoma, he was discharged on 16 January 2022. He developed an infection at the suture site. He was prescribed antibiotics by his GP. On 25 February he attended the Emergency Department at Calderdale Royal Hospital. This was an opportunity to discuss his case with a vascular consultant. It did not happen. On 26 February paramedics attended Peter at home at 10.42. There was evidence available of a herald bleed indicating that a major haemorrhage was likely to happen. This was not appreciated at the time and an opportunity was missed to admit Peter to the specialist Vascular Unit at the Bradford Royal Infirmary where, on the balance of probability, a procedure necessary to save his life could have been undertaken. In fact Peter was admitted to Calderdale Royal Hospital Emergency Department following a second attendance on his at home at 20.32 on 26 February. The concern at that stage was in relation sepsis, not the risk of haemorrhage. He was triaged to level 3. At 22.56 a nurse noted bleeding at the suture site. She reported this to a consultant of the Department, who was not equipped to appreciate its significance. Its not available to conclude on a balance of probability that at that stage would have been sufficient time to intervene to save Peter's life. Peter suffered a catastrophic haemorrhage shortly after 01.05 and consequently died.

Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26 February 2022 would not be expected to possess, the evidence to the Inquest was that they would not have had any training in identifying one, nor any protocol for them to follow.