“Whilst reviews were carried out through the Morbidity and Mortality process for two of…”

The coroner’s concerns

– 1. Whilst reviews were carried out through the Morbidity and Mortality process for two of the departments involved in Mr Jones’ care, one has not been carried out by the Emergency Department, despite concerns raised at inquest by the witness from that team. I am concerned that potential learning, which may make a difference to future patients presenting with atypical aortic dissections, has not been identified or passed on to clinicians within the emergency department and any other relevant departments. 2. Despite Mr Jones’ clinical picture changing whilst in the emergency department, the middle grade doctor reviewing Mr Jones did not alert a senior doctor of the change. I am concerned that training in relation to atypical aortic dissections brought to my attention in evidence at this and a previous inquest, and to my coroner colleague’s attention in inquests they conducted, may not have been ineffective. I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0514

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0