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Coroner warning over patient death after 16-month wait from ‘urgent GP referral’



An elderly patient with coronary artery disease waited an ‘unacceptably long’ period of 16 months from GP referral to surgery, ‘significantly’ deteriorating by the time he finally received treatment, a coroner has warned.

In a report to prevent future deaths, Rachel Galloway, assistant coroner in Manchester City, said she was concerned about the lack of national guidelines for referrals from primary care to secondary care, and from secondary care to tertiary care, for patients with valve disease.

The report looked into the death of 82-year-old Stuart Clarke and concluded he died as a result of the disease – but this was ‘exacerbated by complications arising out of an aortic valve procedure’.

According to evidence provided by Mr Clarke’s consultant cardiologist, the pathway to receive a surgical procedure was ‘unacceptably long’ and if the surgery had been carried out in a timely manner, the outcome ‘might’ have been different.

Giving evidence at the inquest, Mr Clarke’s cardiologist said the normal referral pathway in this case would involve the GP referring the patient to the local hospital – Royal Oldham Hospital. They said it is then the duty of the local hospital to refer to the tertiary centre for special assessment, which was Wythenshawe Hospital.

Mr Clarke went to his GP in February 2018 with symptoms of breathlessness, who referred him to the Royal Oldham Hospital.

Mr Clarke’s family told Pulse the GP referral to the cardiologist, according to their letter, was an urgent referral.

But the hospital kept cancelling or postponing the appointment until they ‘eventually’ saw a cardiologist, who then said he would refer Mr Clarke to Wythenshawe Hospital, according to Helen Clarke, Mr Clarke’s wife.

Mrs Clarke said: ‘The problem was every time we had appointments they were cancelled or postponed and it just went on and on.

‘Every time I rang up, they kept saying “well he’s not an urgent case” but you see, it did say on the letter “you are an urgent referral”. This was in November.’

However, Mr Clarke was not seen at Wythenshawe Hospital until January 2019, and it took until 25 June 2019 for him to undergo necessary transcatheter aortic valve implantation (TAVI) surgery.

Mr Clarke did not recover from surgery and his condition declined. He died on 27 June 2019 at Wythenshawe Hospital.

The coroner outlined concerns relating to the national referral guidelines, and said there still wasn’t national guidance on referrals for patients with valve disease.

Ms Galloway said: ‘By the time that Mr Clarke underwent the TAVI procedure on the 25th June 2019 he had deteriorated and was significantly less well than he had been in the months following his initial presentation to his GP in February 2018.

‘During the course of the inquest, I heard that steps are being taken at local level to ensure more timely intervention in similar cases.

‘However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valve disease.’

The coroner has sent the report to NHS England, NHS Improvement, NICE, the Department of Health and Social Care, and the British Cardiovascular Intervention Society, who are under a duty to respond by 6 January 2020.

Another coroner report recently questioned a hospital chain’s ‘lengthy’ discharge policy after a patient’s GP was left with vital information.

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