The inquest into the death of a 67-year-old man from Stretford in Manchester has concluded that he died of “natural causes contributed to by neglect”.
Peter Young was a retired courier with two grown-up children and seven grandchildren. In 2006, he underwent an aortogram and angiogram at Manchester Royal Infirmary which revealed he had a dilatation of the aorta.
The Senior Coroner for Manchester, Nigel Sharman Meadows, said: “A clinical decision was made that this was not a significant finding and consequently no ultrasound assessment was undertaken. This was a missed opportunity to have assessed and measured the aorta because, had it been greater than 3cm, the deceased would have been subject to surveillance monitoring.”
Had this happened, he continued, it was “possible” that the developing aneurysm would have been diagnosed earlier and Mr Young would have had an operation before 2012.
In 2012 he had a heart attack and subsequently underwent investigations prior to coronary bypass surgery at Manchester Royal Infirmary, on 20 May 2013. During the pre-operative assessments, a large, 7cm aneurysm was noted.
The Coroner found: “This was a serious and life-threatening condition and should have resulted in him being referred to the vascular team for consideration of an elective repair”.
“Due to a combination of human and systemic failings, this did not happen and he was discharged and not followed up. This was a very significant and serious failure and omission of care.”
Peter recovered well from his heart surgery, although he complained of stomach pains from time to time.
On 29 April 2014, Peter was taken by ambulance to the hospital’s accident & emergency department complaining of severe back and flank pain which he had been suffering from for three days. The hospital’s triage team recommended he be seen within the hour but it was three hours until he was seen by a doctor, who diagnosed kidney stones. It was noted that he had a reported 7cm aneurysm in 2013, but no urgent CT scan was undertaken.
A scan was done the next day, showing that the aneurysm had ruptured. He was taken to theatre for emergency surgery but died on 2 May due to multiple organ failure.
On the first day of the inquest, the Coroner adjourned proceedings so that he could visit the hospital and confirm the strength of the new systems the trust says have been put in place to prevent future incidents of this nature.
She says: “The death of her father has had a profound impact on my client and her family, made worse by the knowledge now that it might have been prevented but for human and systemic errors over several years.
“At the same time, she is satisfied with the conclusion of the Coroner, who conducted a thorough investigation that has shown the trust where the mistakes were made. Whilst nothing can bring back her own father, she hopes that as a result of her determination to understand the wider circumstances leading to his death, future deaths will be prevented.