William Albert Winter · Prevention of Future Deaths report

On 10th April 2013 I commenced an investigation into the death of William Albert Winter. The investigation concluded at the end of the inquest on 27th March 2014. The conclusion of the inquest was that Mr William Albert Winter died as a result of surgery for the repair of an abdominal aortic aneurysm.

Mr W A Winter was admitted to William Harvey Hospital on 25th March 2013 after discharge from St Thomas’ Hospital on 22nd March 2013 for the repair of an abdominal aortic aneurysm. He was admitted to the Clinical Decisions Unit at about 8pm at William Harvey Hospital and found in an unresponsive state with rigor mortis at approximately 5am on 26th March. Resuscitation attempts were abandoned soon after.

Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team. They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in an unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed.

I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review. They were unfamiliar with how to do this.