Trevor Paul Hunking · Prevention of Future Deaths report

On 24 June 2015 I commenced an investigation into the death of Trevor Paul Hunking. The investigation concluded at the end of the inquest on 26 October 2016. The conclusion of the inquest was that Mr Hunking died from complications of a necessary surgical procedure.

In July 2003, Mr Hunking suffered a myocardial infarction. After tests, he was diagnosed with diffuse coronary artery disease which was managed medically.

In 2008, following an admission with chest pain he was additionally diagnosed with moderate aortic stenosis. A consultant directed that Mr Hunking have annual surveillance but this did not happen and he was lost to follow-up at this point.

By 2015 Mr Hunking had developed severe aortic stenosis. He was referred for aortic valve replacement and coronary artery bypass grafting, with surgery planned for 21 June 2015.

On 17 May 2015 he was admitted to Royal Cornwall Hospitals Trust with an acute deterioration. He was managed as an in-patient. On 22 May he was accepted for in-patient transfer into Plymouth Hospitals NHS Trust with a target of treatment being provided in the next 7-10 days.

Mr Hunking's transfer had not happened by 11 June 2015. On that date following the personal intervention of his cardiologist his in-patient transfer was expedited and he was admitted to Plymouth Hospitals NHS Trust at approximately 21:00.

Mr Hunking underwent unremarkable surgery the next day but sadly did not recover.
He died in Plymouth Hospitals NHS Trust on 16 June 2015.

Evidence was heard at the Inquest of the steps that have been taken since the death of Mr Hunking to address some of the pressures on the Cardiology and Cardiothoracic resources within the Royal Cornwall Hospital, Truro and Plymouth Hospitals NHS Trust in Plymouth.

The evidence that was heard from ████████, Service Lead for Cardiothoracic Surgery in Plymouth Hospitals NHS Trust as well as ████████ Medical Director, was that the current constraints on the service relate to the provision of qualified Cardiac Intensive Care Unit Specialist Nurses. In short, there are insufficient adequately trained Nurses available.

The Inquest heard that the problem is particularly acute away from London. The capital is able to attract more qualified staff because of the easier transport connections it enjoys with Europe from where, I was told, some of the Nursing specialists originate. In turn, this has led to Plymouth Medical Staff undertaking procedures in London so that patients can have the necessary cardiac intensive care specialist nursing treatment they require.

I heard from NHS England at the Inquest ████████ and he felt that it would be sensible to draw the consequences of the lack of specialist cardiac intensive care nursing staff to your attention. He indicated that you would be well placed to answer what steps were being taken to address the current shortage in the necessary staff.

(1) A shortage of Cardiac Intensive Care Unit Specialist Nurses to deal with patients post-operatively.