A Lost to Follow Up Tragedy
We wanted to write about a case that has hit pretty hard this week.
Paul Harries was an NHS manager who died in October 2024 from a ruptured abdominal aortic aneurysm (AAA), but this wasn’t a clinically silent condition. His aneurysm had been known about, monitored, and then lost.
The Prevention of Future Deaths report should be read carefully by every governance professional in the sector, and can be found here:
Mr Harries AAA was initially diagnosed through the National AAA Screening Programme in November 2020 and referred on to the Vascular team at the Royal Sussex County Hospital. Following an initial assessment which showed a more complex picture, Mr Harries was further referred to the Assessment Unit (VAU) for scanning and monitoring. Monitoring by this team in January 2022 identified the aneurysm had increased in size.
In July 2022, Mr Harries missed a scheduled appointment and scan, no further action was taken and he was lost to follow up.
In February 2023, Mr Harries attended ED after coughing blood for a week. He was scanned and the incidental finding showed a further increase in the size of the aneurysm. However, this information was not present in the discharge summary and his GP was not informed for 14 months.
In April 2024, Mr Harries' GP reviewed him for hypertension; became aware of the history of aneurysm and the more recent results, referring Mr Harries to the Vascular Team as ‘Urgent’.
Unfortunately the Vascular team operated a modified triage system, recategorised Mr Harries as ‘Amber’, which meant he would be triaged within six weeks and reviewed within around 40 weeks. This should have meant he was given the appropriate diagnostic tests by mid-May, and be reviewed by the team by mid-November.
A diagnostic scan in May 2024 showed the aneurysm was difficult to measure. His outpatient appointment, booked on 15 September 2024 was set for 19 October 2024.
Mr Harries died at home on 9 October 2024, two weeks before that appointment.
Mr Harries' family contacted PALS at The University Hospitals Sussex NHS Foundation Trust in February 2025, an inquest being opened on 25 September 2025.
The coroner noted that there were four main areas of concern:
a failure of safety netting and follow-up systems.
Incidental finding communication - incidental findings not routinely communicated if they do not relate to the presenting complaint:
Urgent referral recategorisation: There was a failure to request of the GP their rationale behind the urgency.
Long waits with a condition known to be deteriorating.
The Coroner went on to note that the changes made by the hospital "do not appear to fully resolve the observed weaknesses", and that the hospital remains reliant on three separate referral systems - which rely on three different IT systems.
We at Harbour are not writing this to apportion blame.
The trust has responded with evident commitment to change, and the individuals involved were operating within systems that failed them as much as they failed Mr Harries.
We are highlighting this writing this because every one of these failures has a governance name:
Failure of safety netting systems.
Failure of information governance and clinical communication.
Failure of triage governance and clinical oversight.
Failure of risk stratification and escalation
The trust has since announced significant investment in a new Electronic Patient Record — and we genuinely hope it helps. A well-implemented EPR, with cross-specialty visibility and automated flagging of incidental findings, should make cases like Mr Harries less likely.
But here is the question that kept us discussing this into the night as governance professionals:
What happens when we digitise a broken system?
An EPR doesn't fix a culture where urgent referrals get recategorised without sufficient clinical oversight. It doesn't automatically resolve the question of who is responsible when a finding crosses specialty boundaries. It doesn't eliminate the human judgment call that sits at the centre of triage.
Done well, digital transformation closes the gaps. Done poorly, it makes them faster, more scalable, and so much harder to see.
The governance question for every provider investing in new digital systems right now is not just: will this EPR connect our data?
It's: have we mapped our existing failure points honestly enough to know whether we're building something better — or just digitising what we already have?
None of these questions are unique to large NHS trusts, and Independent providers face the same risks, often with smaller teams, less infrastructure, and digital systems that were never designed to talk to each other.
Effective oversight of patient safety transcends administrative compliance; it represents the critical boundary between a clinical oversight and a tragic outcome.
In the context of Paul’s experience, several governance challenges remain unresolved:
Where does the accountability lie for monitoring patients who miss scheduled imaging?
How do we guarantee that unexpected clinical findings are effectively relayed to primary care?
What are the mechanisms for justifying the recategorisation of urgent clinical referrals?
Which specialty assumes primary responsibility when a diagnosis spans multiple departments?
Any framework unable to address these fundamental queries is fundamentally compromised.
Without clear answers, we risk accelerating the pace of institutional failure.
Rest in peace, Paul Harries. We owe a debt of gratitude to his family and the coroner for their commitment to ensuring the healthcare sector learns from this loss.
Source: HSJ, 2025; https://www.judiciary.uk/prevention-of-future-death-reports/paul-harries-prevention-of-future-deaths-report
#PatientSafety #HealthcareGovernance #PSIRF #DigitalSafety #EPR #ClinicalGovernance #HarbourGovernance #IndependentHealthcare
