Mr Andrew Cox, the Coroner at the inquest into the death of Robert Donson, a 71-year-old cattle farmer from Foxhole in Cornwall, has found that Mr Donson died of natural causes. He did, however, identify failings on the part of the GP treating him and the Royal Cornwall Hospital Trust.
The inquest, held at Plymouth Coroner’s Court on 16 September 2015 heard how Mr Donson died on 30th September 2014 at Derriford Hospital in Plymouth after an untreated abdominal aortic aneurysm (AAA) ruptured causing multiple organ failure. The aneurysm had gone unchecked and untreated for years, despite an ultrasound scan in 2009 that identified a 4cm swelling on his aorta, mandating a referral to the Royal Cornwall Hospital’s vascular team for review and regular monitoring.
Mr Donson went for the scan at the Royal Cornwall Hospital after complaining of abdominal pain and feeling generally unwell. The incidental finding that he had a 4cm AAA meant that a letter was sent to his GP for this to be followed up. The inquest heard evidence that the GP did receive a letter from the consultant at the Trust but failed to take further action. This was not followed up by the Trust.
When Mr Donson became seriously unwell and collapsed in September 2014, hospital medical staff initially diagnosed diverticulitis (a digestive condition) and then gallstones, based on the symptoms he presented with at that time. Only later following a CT scan was a 7cm AAA diagnosed. As this was over a weekend when a vascular surgeon and a vascular radiologist were not available at Treslike, the decision was made to observe Mr Donson over the weekend and discuss with the consultant vascular surgeon on the Monday morning. It came out in evidence at the inquest that when this CT scan was subsequently reviewed the results were worrying and showed signs of pre-rupture.
Before this discussion could take place however, Mr Donson collapsed and an emergency CT scan was sought which revealed that the AAA ruptured. Mr Donson was thereafter transferred to Derriford by ambulance and on his arrival efforts were made to operate. Doctors were unable to save him.
The Coroner, Mr Andrew Cox, gave a short form verdict, stating that:
In Sept 2009 an incidental finding of an aortic swelling was made to his GP. This was not acted on. On 26 September 2014 Mr Donson was admitted to Royal Cornwall Hospital NHS Trust and was diagnosed with Diverticulitis and then Gallstones, both of which he had previously suffered. A 7cm AAA was subsequently identified but not believed to be causative of his symptoms. On 28 September 2014 the AAA ruptured. Mr Donson was transferred to Derriford Hospital where despite treatment he died.
The Coroner found that Mr Donson died as a result of natural causes.
The incidental finding of the AAA report in 2009 was missed by Mr Donson’s GP. There could have been a direct referral by the hospital internally to the vascular team however the Coroner was of the view that this responsibility primarily lay with his GP. Had the AAA been noted and acted upon Mr Donson would have been referred to the vascular team for urgent review.
During the inquest it was confirmed by both the GP and the Trust that following Mr Donson’s death they have reviewed the case and made changes to their policies and procedures including:
- There has been a change in procedure at the GP practice to the coding of correspondence from the Trust to the GP to ensure that letters of this nature are not missed.
- The Trust has clarified their procedure to be followed for resolving situations where incidental findings are made, which includes ensuring that the vascular surgeon and vascular radiology consultants are available 24/7. This will come into force in October 2015. Had this not been the case the Coroner made it clear that he would have exercised his duty under Regulation 28 to force them to address this.
Mr Donson’s son David says: “We have lost a father and grandfather whose death leaves a gap in all our lives. My father was well known in the local farming community and his farm is now a quieter place without him – the world has lost one of life’s great characters.
“We are grateful to the Coroner for his thorough investigation, which has given me and my family an insight into the circumstances surrounding my father’s death. I remain shocked, that his GP missed a vital communication from the hospital regarding his 2009 scan and that subsequently neither the hospital consultant nor the GP followed this up. I believe that if this condition had been treated earlier my father may well still be with us today.”
Rachel Heelis, medical negligence lawyer at Hodge Jones & Allen in Cornwall and Devon is representing the family. She says: “The family are pleased with the conclusion that the Coroner reached as well as his findings. We were pleased to hear during evidence that lessons have been learned following Mr Donson’s death and that procedures have been changed by both the GP and Royal Cornwall Hospitals NHS Trust. This is of some comfort to the family, although of course it will not bring their loved one back. We hope that the changes made will ensure that this situation or a similar one does not happen to anyone else in the future.”
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Notes to editors:
Hodge Jones & Allen was founded in 1977 in Camden and has 200 staff based in Euston NW1. The firm practices personal injury, clinical negligence, civil liberties, family law, wills and probate, housing, dispute resolution, criminal defence and serious fraud.
Hodge Jones & Allen has a base in Cornwall serving clients in Cornwall, Devon and the South West which was established in 2013