NHS manager died after being ‘lost to follow up’

An NHS manager died after an urgent referral was “recategorised” and a triage time of six weeks was arranged instead.

Mr Paul Harries was scheduled to undergo a scan in July 2022 as the result of a 2020 test showing an abdominal aortic aneurysm (AAA) was increasing in size. However, he did not attend and was then “lost to follow-up”, according to a coroner’s report into his death.

In February 2023, Mr Harries attended accident and emergency department for an unrelated reason. A scan showed the AAA had grown even larger. However, his GP was not informed of this finding until April 2024. 

The GP made an urgent referral to the vascular surgery team at the Royal Sussex County Hospital in Brighton. However, the surgeon who was sent the referral rated Mr Harries as “amber”, meaning he would be triaged within six weeks and be seen within 40.

A scan in May 2024 showed the AAA was “difficult to measure”, and Mr Harries was given an outpatient appointment in October of that year. However, he died at his home in Brighton two weeks before the appointment.

His family contacted the hospital in February 2025, raising concerns that he had not been followed up appropriately, and an inquest opened in September last year after a patient safety incident investigation was concluded.

West Sussex, Brighton and Hove coroner Joseph Turner said that the changes made by the hospital since his death “do not appear to fully resolve the observed weaknesses” that saw an urgent GP referral not resulting in appropriate action by the hospital. 

He said that the hospital remained reliant on three separate referral systems, and the emergency department had an inconsistent approach to reporting incidental findings in existing conditions to GPs.

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Source: HSJ, 29 June 2026