Philip Richard Hayes · Prevention of Future Deaths report

On 24 April 2019 I opened an investigation into the death of Philip Richard Hayes aged 60yrs.

The investigation concluded at the end of the inquest on 29 October 2019.

The conclusion of the Inquest was:

Medical cause of death: Aortic dissection

Conclusion: Natural causes

On 14 April 2019 in or around 13:13 Philip Hayes suffered an aortic dissection.

Initial symptoms were chest and flank pain.

At 13:13 a 999 call was made to summon urgent assistance.

The call was triaged at 13:16 and categorised C2 response (18 minutes).

At 13:23, 13:27, 13:31, 13:45 and 13:59 further calls reporting new symptoms and a deteriorating condition were made.

These subsequent calls did not result in a reassessment of the original categorisation nor did the calls result in the case being referred for clinical input.

Ambulance technicians arrived at 14:02 and paramedics at 14:15 (1 hour and 2 minutes after the original call).

Philip Hayes was transported to the Northumbria Specialist Emergency Care Hospital, arriving at 15:13.

His dissection was diagnosed following CT scan at approximately 23:56 when arrangements for his transfer to Freeman Hospital, Newcastle for specialist vascular care were made.

Notwithstanding maximal care and treatment he died there on 18 April 2019

(1) Delay in ambulance dispatch
Call categorised C2 received response 1 hour 2 minutes after
original call

(2) Failure to conduct reassessment of C2 category notwithstanding 5
subsequent calls describing additional symptoms and a deteriorating
condition

(3) Inconsistency in approach and answers to algorithm question designed
to indicate risk of aortic aneurysm/rupture/dissection

(4) Calls triaged by health advisors with limited medical training and no
medical qualifications

(5) Inconsistency in approach to referral for clinical input

(6) Appropriateness of triage by algorithm. Insufficient if any weight given
to actual reported symptoms and indicators of a medical emergency