The Wokingham Paper

Coroner calls for changes after woman dies of ‘missed’ aneurysm

The inquest was held at Reading Town Hall
The inquest was held at Reading Town Hall

A WOMAN from Wokingham died after doctors missed a large aneurysm in her abdomen.

Violet Livene Nelson, 80, who was known as Sue, died on September 17, 2016 after a thoracic aortic aneurysm ruptured causing her  to collapse at her home in South Drive.

An inquest into her death, held at Reading Town Hall on Thursday, November 23, heard how Mrs Nelson had been diagnosed with a small abdominal aortic aneurysm in March 2012, which only measured 3.6cm in diameter, meaning her GP did not think it necessary to refer her to a specialist vascular surgeon.

Mrs Nelson was instructed to book herself in for review appointments every year, which would involve a scan to check on the growth of the aneurysm, which she did in 2013 and 2014.

When she was reviewed in 2013, the aneurysm had grown to 3.7cm, but when she went back in 2014, it had shrunk to 3.4cm.

The size of an aneurysm at which a patient is referred to a specialist is 5.5cm, meaning that Mrs Nelson’s was well below the required size, and her GP was happy for her to continue with annual reviews.

However, Mrs Nelson stopped making the review appointments in 2015 and 2016, and because she had never told her husband, Robert, about her condition, he could offer no explanation as to why she didn’t continue to go.

He told the coroner: “I don’t know if she forgot or if it slipped her mind, if I had known about it I would have helped her however I could.”

In a statement read out to the inquest, Mr Nelson explained that his wife had been unwell for several days prior to her death, but on the morning of September 17 she had appeared to be better.

He left the house at around 9.20am to do some shopping as he usually did.

When he returned at around 10.10am, he went into the garden to do some jobs before making his way into the house.

When he entered the kitchen, he found his wife collapsed on the floor, as if she had fallen from a stool. Mr Nelson started CPR whilst calling for an ambulance.

Paramedics arrived shortly afterwards and continued to deliver CPR, but it became clear that there was nothing that could be done to save Mrs Nelson.

A post-mortem carried out at Wexham Park Hospital found that Mrs Nelson had suffered a rupture of a large thoracic aortic aneurysm, measuring around 10cm, which was much larger and higher up than the abdominal aortic aneurysm she had been diagnosed with.

The inquest heard how Mrs Nelson’s GP had changed several times during the last years of her life, but her most recent GP at Wokingham Medical Centre, Dr Amandeep Grewal, who has since left the practice, said that she had not been misdiagnosed, but agreed that Mrs Nelson should have been referred to a specialist much earlier in her treatment.

Currently, only men over the age of 65 are invited for screening for abdominal aortic aneurysms, and as the offer is not currently open to women, there was no guidance in place for Mrs Nelson’s case.

The coroner, Mr Peter Bedford, sought the advice of a specialist vascular surgeon, Jack Collin, who agreed that a GP would not have known to refer Mrs Nelson to a specialist with the condition she was presenting, especially as it appeared that the aneurysm was decreasing in size.

He said in a statement: “If she had been referred, a specialist would have carried out a more thorough scan, possibly an MRI, to determine whether there was anything else going on.

“Someone with more specialist knowledge would have suspected that the suprarenal abdominal aortic aneurysm was in fact the lower end of a much larger aneurysm.”

He also suggested that the sonographer carrying out the scan of Mrs Nelson wasn’t qualified to offer advice, and should instead have consulted with a radiographer over the results, which could have led to a referral.

Mr Bedford said: “A GP wouldn’t have known any of this. He would have seen the encouraging results in front of him, and told his patient there was nothing to worry about.

“There clearly needs to be a change here.”

The coroner concluded to use his powers to submit a report under Regulation 28 to prevent future deaths, suggesting that GPs are issued guidance for treating a patient diagnosed with an abdominal aortic aneurysm.

Dr Grewal added that the system at Wokingham Medical Practice had changed as a result of Mrs Nelson’s death, meaning that all patients presenting with an abdominal aortic aneurysm are referred to a specialist, regardless of its size.

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