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Tom Challacombe represents family of Cornish Farmer at an inquest that identifies failings of GP and Royal Cornwall Hospital Trust

30th September 2015

Thomas Challcombe represented the family where Mr Andrew Cox, the Coroner at the inquest into the death of Robert Donson, a 71-year-old cattle farmer from Foxhole in Cornwall, has found that Mr Donson died of natural causes. He did, however, identify failings on the part of the GP treating him and the Royal Cornwall Hospital Trust.

The inquest, held at Plymouth Coroner’s Court on 16 September 2015 heard how Mr Donson died on 30th September 2014 at Derriford Hospital in Plymouth after an untreated abdominal aortic aneurysm (AAA) ruptured causing multiple organ failure. The aneurysm had gone unchecked and untreated for years, despite an ultrasound scan in 2009 that identified a 4cm swelling on his aorta, mandating a referral to the Royal Cornwall Hospital’s vascular team for review and regular monitoring.

The incidental finding of the AAA report in 2009 was missed by Mr Donson’s GP. There could have been a direct referral by the hospital internally to the vascular team however the Coroner was of the view that this responsibility primarily lay with his GP. Had the AAA been noted and acted upon Mr Donson would have been referred to the vascular team for urgent review.

During the inquest it was confirmed by both the GP and the Trust that following Mr Donson’s death they have reviewed the case and made changes to their policies and procedures including:

There has been a change in procedure at the GP practice to the coding of correspondence from the Trust to the GP to ensure that letters of this nature are not missed.
The Trust has clarified their procedure to be followed for resolving situations where incidental findings are made, which includes ensuring that the vascular surgeon and vascular radiology consultants are available 24/7. This will come into force in October 2015. Had this not been the case the Coroner made it clear that he would have exercised his duty under Regulation 28 to force them to address this.

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Tom Challacombe represents family of Cornish Farmer at an inquest that identifies failings of GP and Royal Cornwall Hospital Trust