Mr John Higgs · Prevention of Future Deaths report

On 22nd December 2016 I commenced an investigation into the death of Mr John Higgs. The investigation concluded at the end of the inquest on 7th April 2017. The conclusion of the inquest was that Mr Higgs died from

1(a) Ruptured Abdominal Aortic Aneurysm

2. Stroke, Frailty of old age

A narrative conclusion was recorded as follows:

Mr Higgs died in Barnsley General Hospital on the 18th November 2015 as a result of a ruptured abdominal aortic aneurysm.

In March 2011, Mr Higgs attended Barnsley General Hospital and underwent a CT scan which identified the presence of a 6cm abdominal aortic aneurysm. This finding was not communicated to Mr Higgs despite him attending at the hospital on a number of occasions following the scan. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015.

Mr Higgs attended Barnsley General Hospital on the 18th November 2015 following a fall and vacant episode. It was initially thought that Mr Higgs had suffered a further stroke but an ultrasound scan revealed a 6.6cm abdominal aortic aneurysm which was leaking. He Higgs died later that same day.

After Mr Higgs death, his wife received the death certificate and sent a letter to the hospital asking why she had not been informed that he husband had an aneurysm. This was investigated by the Trust and it was found that Mr Higgs had undergone a CT scan in March 2011 and the scan had identified the presence of a 6cm abdominal aortic aneurysm but the results had been overlooked at the time and therefore not communicated to Mr Higgs, other clinicians or his general practitioner.

The evidence at the inquest was that presence of the abdominal aortic aneurysm was an unexpected finding on the CT scan. The report had been seen by the Consultant Surgeon in charge of the care, but he did not act upon these results because Mr Higgs was attending clinic 5 days later and therefore the Consultant would discuss them with the patient. At this time, the trust relied on paper records. Mr Higgs attended clinic and was seen by a junior doctor who either did not review the CT report or it was unavailable because it was still with the consultant awaiting filing on the patient records. There was no evidence in court of a safe system of communication at the time (2011).

Mr Higgs attended at the hospital on a number of occasions after the scan results were available in 2011 and was seen by several different doctors but the CT scan results from 2011 were not looked at. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015.

The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings.

The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings.

The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again.