Inquest into the Death of Kevin George HOWLETT

83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)

An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on a lumbar spine X-ray in August 2021, but confirmatory ultrasound and CT imaging were not performed until February 2022. Critical failures included: the PMO's failure to indicate urgency when requesting imaging despite the large aneurysm size, the AAA not being added to the patient's Active Problem List in the electronic health record, and delayed communication of imaging results. While Dr B. estimated an elective repair would have had 1-2% mortality with likely good long-term outcomes, the patient died from rupture before intervention. The coroner found the overall quality of supervision, treatment and care unacceptable, though general medical management was otherwise comprehensive.