Peter Ross
4 Nov 2022 · Coroner Graeme Irvine · East London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. misreported CT C-spine results
“1.A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.”
2. failure to document and escalate abnormal CT findings
“2. Following that report, during the initial referral of Mr [name redacted] to neurosurgery, the reviewing surgeon noticed an abnormality in Mr [name redacted] CT Spine, made no note of his finding and did not escalate his finding to any other clinician.”
3. failure to review CT images before surgery
“3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.”
4. communication failures among multidisciplinary team
“4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr [name redacted].”
5. poorly maintained clinical records
“5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Later report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Closely relatedConfidence 0.90 · high
This report
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Later report
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Responses
2022-0354-Response-from-Barking-Havering-and-Redbridge-University-Hospitals.pdf ↗· Barking
Stated action
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
2022-0354-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“The Trust has provided assurance to CQC that this specific incident relating to Mr [name redacted] was presented at the Trust-wide Patient Safety Summit. Proposed teaching sessions for staff were delivered, improvements were made to documentation, and implementation of these improvements were audited.”