Concern over Countess of Chester patient's death as 'opportunity missed'

A coroner has raised her concerns over the death of a 79-year-old man who had collapsed at home with severe stomach pain, citing "a missed opportunity" when he was admitted to the Countess of Chester Hospital.

Thomas Wakefield was taken to A&E at 10.22pm on September 23 last year after suffering severe stomach pain for three days, resulting in his sudden collapse at home earlier in the day. He sadly died from natural causes the following day, an inquest held on April 10 concluded.

Now, senior coroner for Cheshire Jacqueline Devonish has written to NHS England to report her concerns. In a prevention of future death report, she states that although "it is not possible to say on balance of probabilities whether Mr Wakefield would have survived if the correct diagnosis had been made on admission", there was "a missed opportunity to review the diagnosis of pancreatitis on admission" which would provided a 50 per cent chance of survival.

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Describing the circumstances surrounding Mr Wakefield's death, the coroner said: "The clinicians were not made aware of the collapse at home. He was promptly assessed in A&E for concerns with acute kidney injury. The plan was to prescribe intravenous fluids due to hypotension.

"There was a delay in medical assessment. A CT scan was considered at 05:59 but not ordered or completed. This was a missed opportunity to review the diagnosis of pancreatitis on admission and provide a 50% chance of survival. He was sadly found deceased in bed at 16:10 hours on 23 September 2023."

Her report concludes: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

"During a review of the NICE guidelines entitled 'Abdominal Aortic Aneurysm: diagnosis and management', and the international guidance, it became apparent that there is a lack of caution within the guidance about the recognised risk that abdominal aortic aneurysm and acute pancreatitis are known to be diagnoses misidentified by clinicians. These conditions can have similar presenting features.

"Whilst the guidance states that if there is uncertainty about a diagnosis of pancreatitis as not all criteria are met, imaging tests should be undertaken, this does not specifically require the exclusion of abdominal aortic aneurysm which is fatal if untreated. The clinical presentation alongside amylase results in this case met the criteria for a diagnosis of pancreatitis."

An NHS England spokesperson said: "NHS England extends its deepest sympathies to the family and friends of Thomas Wakefield. We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course."

The Countess of Chester Hospital has been approached for comment.

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