Keith David FOORD · Prevention of Future Deaths report

On 09 May 2022 I commenced an investigation into the death of Keith David FOORD aged 76. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was that:

Dr K D Foord sustained a Type A Aortic dissection on 2.5.22. His symptoms caused him to request an ambulance to go to the A and E Department at Conquest Hospital, Hastings arriving at 9.30am that day. An accurate diagnosis was made at 12 midday and arrangements were made with Royal Sussex County Hospital, Brighton to transfer his care to their cardiac surgery unit. A Category 2 ambulance was called for which took 1hr 19 minutes to arrive, 1 hr later than the 18 minute response time required by a Category 2 case.
Dr Foord was taken to theatre and underwent a lengthy operation, but the right coronary artery had completely detached from the aorta by the time surgery began which disaffected significantly his chances of survival.
Dr Foord died at 7.30am on 3.5.22, the cause of death being:
1a) Acute type A Aortic dissection (Emergency Aortic Repair 25/5/22).

Dr Foord died as a result of an Acute type A Aortic Dissection in spite of undergoing emergency repair on 2nd May 2022. He had presented to A and E at The Conquest Hospital where the correct diagnosis was made in a timely manner. He required an ambulance to take him to Royal Sussex County Hospital, Brighton where the regional cardiac surgery is undertaken. His case was categorised as 2 for response time for the ambulance service when all of the clinical, paramedic and expert witnesses whose evidence I heard at the inquest advised that it should be correctly categorised as a 1 given the critical requirement for emergency surgery.

namely that for aortic dissection requiring emergency surgery and inter facility transfer, the category of this type of case for transfer should be raised to category 1.