Frank Hayward
29 Mar 2018 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. missed diagnosis of odontoid peg fracture and subdural haemorrhage
“failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner”
2. inadequate cervical collar provision and delayed urgent CT scan
“poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff.”
Responses
Frank-Hayward-Response.pdf ↗· Sandwell and West Birmingham Hospitals NHS Trust
Stated action · 16th May
“The revised draft guideline was recently shared at our Quality Improvement Half Days on 16th May, asking teams and specialties to take note of the requirements of the guideline and to highlight any challenges they see in implementing the changes and providing any solutions.”