A patient was never told about a tennis ball-sized aneurysm which ended up killing him nearly five years after it was first discovered in South Yorkshire
John Higgs collapsed suddenly in November 2015 and was taken to Barnsley Hospital, where he died later that day.
A scan revealed a ruptured aneurysm - a bulge in a blood vessel - which at 6.6cm wide was around the size of a tennis ball, in his abdomen.
Only after he died did his wife learn an earlier scan at the hospital in March 2011 had identified a 6cm swelling in the same location, which neither she nor he were ever informed about and which was not flagged up to other clinicians or his GP.
That meant he was never referred to specialist vascular surgeons and was denied the opportunity to consider options for treatment before his sudden death.
A coroner has warned more patients could die unless the hospital trust changes its procedures to prevent a similar blunder occurring.
Louise Slater, assistant coroner for South Yorkshire, wrote to the health secretary raising her concerns following an inquest into Mr Higgs' death, which concluded last month.
In a report also sent to the hospital's chief executive and Mr Higgs' family, she states: "In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you."
Ms Slater's report details how the CT scan in March 2011 identified an aneurysm but the results were 'overlooked' at the time.
She said the consultant surgeon had seen the results but the unexpected finding was not acted upon as Mr Higgs was attending clinic five days later and it was expected they would be discussed then.
However, the junior doctor who saw Mr Higgs at that appointment either did not review the CT report or it was not available because it was still with the consultant awaiting filing.
Mr Higgs subsequently attended the hospital on numerous occasions and was seen by several different doctors but the scan results were never looked at.
Ms Slater said in her report that although the hospital has moved since 2011 from a paper system to an electronic one, any unexpected and potentially life-threatening radiological findings are still only flagged up to the consultant in charge of the care and it is up to that single doctor to notice and input the information.
She said the inquest also heard there was no facility to place a 'red flag' on the system to increase the likelihood of other clinicians being alerted to the danger.
Dr Richard Jenkins, interim chief executive at Barnsley Hospital, said: “We would like to offer our sincere condolences and apologise to the family of Mr Higgs for the deficiencies in the care he received.
“The trust had undertaken an investigation into Mr Higgs' care prior to the inquest and we are carefully studying the coroner's findings to ensure that all necessary steps have been taken to prevent a similar situation from arising in future. Patient safety is paramount at the trust and we will continue to work to ensure our services are as safe as possible.”
BREAKING: South Yorkshire man hit with hammer, slashed with machete and throttled in armed raid
UPDATE: Sheffield's Crystal Bar 'reviewing security procedures' after woman is raped
Alan Biggs at Large: Why I think Sheffield Wednesday are flying in the right direction under the right type of foreign ownership
Alan Biggs at Large: Ched Evans’ signing is a gamble for Sheffield United - but surely one worth taking
VIDEO: Dramatic dashcam footage captures moment DUCK smashes into car windscreen in Sheffield city centre
Deadly 'zombie drug' Spice seized during raids on South Yorkshire homes
Sheffield brothers who lived lavish lifestyle as kingpins of drug empire are jailed
Sheffield rapist branded 'dangerous' and 'nasty' by police
South Yorkshire drug dealer concealed hundreds of pounds of crack cocaine in a Kinder Egg
Download The Star's mobile app now for FREE