Prevention of Future Deaths report: Andrew Guillaume (3 January 2024)

Summary

Andrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital.

Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.

Content

The Coroner noted her matter of concern in the case was the inability of Consultants and staff to get through to the switchboard at UHCW on two occasions.

She stated that a previous incident in which a similar concern had been raised, which had led to provision of an emergency GP phone number, that can be used by the clinical teams at South Warwickshire University NHS Foundation Trust, which is manned 24 hours a day and is prioritised over other calls. However she noted that the Cardiology team had not been aware of this, nor did they have the telephone number.

The Coroner also noted that Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023, as the referral had not been completed. She said that had the referral been completed, the team at UHCW could have prioritised the patient’s transfer.