“The ultrasound scan of Mr Wood's AAA completed in June 2017 measured the aneurysm as 5.5…”
Dated 21 Oct 2020, from the coroner for East London. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 16 Dec 2020. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated21 Oct 2020
- Deadline16 Dec 2020
- Published on judiciary.uk4 Dec 2020
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Public Health England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2020. A reply may have been sent and not yet published. |
| Barking, Havering and Redbridge University Hospitals NHS TrustNamed in the report as “The Barking, Havering and Redbridge University NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2020. A reply may have been sent and not yet published. |
| Clinisys UK | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2020. A reply may have been sent and not yet published. |
| Maylands Health Care | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
The ultrasound scan of Mr Wood's AAA completed in June 2017 measured the aneurysm as 5.5 ems. The report simply stated the size and position of the AAA. Expert evidence heard by this court confirmed that the nationally accepted, established threshold for intervention in AAAs was when an aneurysm measured 5.5cms (or greater). In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient's GP for assessment. The GP was to decide whether to refer the patient on for treatment. In Mr Wood's case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result. In the light of the sad facts of Mr Wood's death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include advice to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral. My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood's case, is capable of failure.
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, 2020-0212
- Added to Minute Book
- 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
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