Coroner warns lack of standard pathway for aortic dissection is risking lives in the East Midlands

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By Daniel Pye

Delays in transferring patients for cardiac surgery caused by a failure to implement a standard pathway is putting lives at risk, a coroner has warned after two patients died.

Malcolm Budd died in February aged 65 after being admitted to the Royal Derby Hospital (RBH) and was diagnosed with an aortic dissection.

Nottingham University Hospitals NHS Trust (NUH) cardiac team confirmed they were unable to deal with this type of surgery and recommended a transfer to Glenfield Hospital (GH) in Leicester.

Budd died shortly after arriving at GH, more than eight hours after his admission to RBH.

Coroner Dianne Hocking said the Acute Aortic Dissection Pathway Toolkit (dated March 2022) had not been implemented in the East Midlands and this had led to delays in transferring patients to the GH “where potential lifesaving surgical treatment can take place”.

The prevention of future deaths report (POFD) has been published before the conclusion of the inquest, because the coroner said the risk to life was such that her report “cannot wait”.