George Leonard Parkes · Prevention of Future Deaths report

On 4th January 2013 I commenced an investigation into the death of George Leonard Parkes, age 84. The investigation concluded at the end of the inquest on 4th October 2013. The conclusion of the inquest was:
Medical cause of death

1a. RUPTURED ABDOMINAL AORTIC ANEURYSM

Conclusion of the Assistant Coroner as to the death
Died during surgery being carried out for a ruptured abdominal aortic aneurysm.

Please see attached.

I attach the summing up in relation to this case which essentially involves the situation where a patient with an abdominal aortic aneurysm was “lost to follow up”. The consequences were that it meant that his aneurysm became so big that it ruptured and he died. Potentially, this was a preventable death as if he was eligible, he would have been given the opportunity of having fenestrated endovascular repair which probably would have meant he would not have died when he did. It has been suggested to me by the witnesses that having a specialist nurse clinic (enabling open monitoring of patients with abdominal aortic aneurysms) and dedicated procedure database/register, would prevent this situation happening again. The guidance from the Chief Coroner is that in writing these Reports, the Coroner does not make a very specific recommendation and I do not in this case. I do, however, support the Consultant Vascular Surgeons at the Queen Elizabeth Hospital (specifically ████████, in actions such as the nurse clinic being set up, to prevent future loss of life, and any other measure(s) which will prevent future “lost to follow-up” situations.