Prevention of future deaths report: Malcolm Budd (21 July 2026)

Summary

A Pre-Inquest Review Hearing took place on the 21 July 2026 which heard that Mr Budd died on the 24 February 2026 aged 65 years.  He was admitted to the Royal Derby Hospital on the 24 February 2026 at 12:26. He presented with sudden onset left sided jaw pain which radiated to the occipital region and thoracic spine.  Suspecting aortic dissection or subarachnoid haemorrhage a CT scan was requested along with a D Dimer at 15:55. He was diagnosed with an aortic dissection following CT scan at 17:45 (reported at 18:03). 

There was discussion between the Year Two Foundation doctor and the on call cardiac surgeon  in  Derby. University  of  Hospital  Nottingham  cardiac  team  were contacted  who  confirmed  that  they  were  unable  to  deal  with  this  type  of surgery and Derby was advised to contact Glenfield who agreed to have Mr B admitted for surgery.  Adult Critical Care Co-Ordination and Transfer Service (ACCOTS)  was  contacted  and  transferred  Mr  B  to  Glenfield  Hospital, Leicester, arriving at 20:26 in ventricular fibrillation from which he could not be recovered and died at 20:45 despite resuscitation attempts.

Content

Matter of concerns

It has come to my attention that, despite reassurances in another, very similar case in this jurisdiction, the Acute Aortic Dissection Pathway Toolkit (dated March 2022) has not been implemented in the East Midlands.

This is a toolkit which aims to standardise and improve aortic dissection pathways and to establish a framework for regional networks, including governance structure, clearly defined patient pathways, multidisciplinary team processes and formal outcome monitoring arrangements. 

I am aware that there was an intention to facilitate the development of a comprehensive regional Standard Operating Procedure (SOP), consistent with arrangements already established in other regions. To date no comprehensive regional SOP for the management of acute aortic dissection has been formally implemented in the East Midlands.

I believe that the lack of this agreement between local hospitals has led to delays in transferring patients with acute aortic dissection from tertiary hospitals within the East Midlands to the University Hospitals of Leicester (Glenfield) where potential lifesaving surgical treatment can take place, as is the case in this investigation and in a previous inquest that was heard by me on the 21 April 2026. Both patients were received by Glenfield Hospital in extremis and died before any operation could take place.

I am aware of further instances where patients have been redirected to Glenfield only after significant deterioration in their condition despite the clinical understanding that, in acute aortic dissection, each hour of delay is associated with a measurable increase in mortality risk.

Related reading:

• Malcolm Budd: Prevention of future deaths report (part 2)