Doctors never told patient of aneurysm the size of golf ball

Coroner warns of failings in system as man dies five years after abdominal swelling was detected

A MAN died after doctors found an aneurysm the size of a golf ball but failed to tell him or take any action for five years, an inquest heard.

A coroner has written to Jeremy Hunt, the Health Secretary, following the death of John Higgs, who was seen repeatedly in hospital without anything being done about the bulging blood vessel that went on to kill him.

Mr Hunt has been warned of “a risk that future deaths will occur unless action is taken” at Barnsley Hospital in South Yorkshire.

The pensioner collapsed in November 2015 and was taken to the hospital, where he died later that day.

A scan revealed a ruptured abdominal aortic aneurysm, a swelling in the main blood vessel that leads away from the heart, down through the abdomen to the rest of the body.

A ruptured aneurysm can cause massive internal bleeding and is usually fatal.

Mr Higgs’s aneurysm measured 2.6in and was classed as large.

It was only after his death that his wife learnt that he had undergone a CT scan in March 2011, which had found a 2.3in aneurysm in the same location.

Neither Mr Higgs nor his GP had been told about the aneurysm and the consultant in charge of his case had taken no action over it, the inquest found.

Although the surgeon was aware of the finding, he had not acted, because he intended to do so when the patient attended his clinic five days later, the inquest heard.

However, when Mr Higgs kept the appointment, he was seen by a junior doctor, who either failed to review the report of the scan, or never saw it, because it was yet to be filed. The find- ing from the 2011 scan was not reported to Mr Higgs’s GP.

As a result, the pensioner was never referred to specialist vascular surgeons and “did not have the opportunity to consider any further treatment options prior to his sudden collapse”, the coroner said.

Although Mr Higgs returned to hospital on a number of occasions after the scan, none of the doctors who saw him ever knew of it.

In her letter to the Health Secretary, Sarah Slater, assistant coroner for South Yorkshire, told Mr Hunt said that the system of communication was not safe.

She warned: “there is a risk that future deaths will occur unless action is taken”.

The inquest heard a radiology protocol was in place at the trust for “unexpected cancer pathology”, where results were sent to the treating consultant and the multidisciplinary team cancer coordinator for action. However, there is no similar protocol for “non-cancerous but significant and potentially life-threatening findings” such as an aneurysm.

Although the trust had since moved to an electronic system, the coroner said significant findings were still only sent to the consultant and no “red flag” was in place to alert other clinicians.

Richard Jenkins, interim chief executive at the trust, apologised to the family of Mr Higgs for deficiencies in his care.

He said: “The trust had undertaken an investigation into Mr Higgs’s care prior to the inquest and we are carefully studying the coroner’s findings to ensure that all necessary steps have been taken to prevent a similar situation from arising in future.”