Roger Wood · Prevention of Future Deaths report

On 18 February 2019, this court commenced an investigation into the death of Roger Wood. The investigation concluded at the end of the inquest on 14th October 2020. I made a determination of a narrative conclusion in which I concluded that Mr Wood’s death was as a result of natural causes, contributed to by a lack of care. The medical cause of death was: 1a Ruptured Abdominal Aortic Aneurysm

Mr Roger William Wood was diagnosed as suffering from an Abdominal Aortic Aneurysm ("AAA") and since 2005 had been subject to annual surveillance to monitor that condition.

On 5th June 2017 Mr Wood underwent an ultrasound scan that measured the AAA to be 5.5 cms in AP diameter. The measurement was significant, the AAA had grown to a size where the risks presented by the condition outweighed the risk of treatment, accordingly at this point, Mr Wood ought to have been referred for treatment.

In 2017 the local procedure in cases of this type was for imaging reports to be sent to the patient’s GP, and for the GP to refer the matter to a vascular surgery specialist.

A report of the scan was sent to Mr Wood’s GP, Dr ████████ by the hospital sonographer utilising an electronic reporting system Cyberlab.

The scan was received by Dr ████████'s surgery, but not acted upon. Mr Wood was not referred to a specialist.

The following year, the annual scan measured the AAA to be 5.96 cms in diameter. This time, the results were properly assessed by the GP and a referral was made to vascular surgeons.

The referral led to a plan to treat the AAA with an “EVAR” stent. Regrettably, Mr Wood could not undertake this treatment as before the appointed date he sustained a fatal rupture to the AAA on 12/2/19.

Expert evidence heard by this court confirmed that had a similar treatment plan been commenced in 2017, it is likely that Mr Wood would have been protected from a future AAA rupture for life.

The ultrasound scan of Mr Wood’s AAA completed in June 2017 measured the aneurysm as 5.5 cms. The report simply stated the size and position of the AAA.

Expert evidence heard by this court confirmed that the nationally accepted, established threshold for intervention in AAAs was when an aneurysm measured 5.5cms (or greater).

In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient’s GP for assessment. The GP was to decide whether to refer the patient for treatment.

In Mr Wood’s case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result.

In the light of the sad facts of Mr Wood’s death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include auto mailed to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral.

My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood’s case, is capable of failure.