Worcestershire Acute Hospital NHS Trust
NHS / Health Body
Action Taken
Worcestershire Acute Hospitals NHS Trust discussed the learning from the investigation via teaching and board rounds, sent an email containing this learning to all doctors including locums, and circulated a lesson of the week reminding staff of the need to read both parts of a CT scan report. (AI summary)
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Dear Mr Reid
Re Regulation 28 Report to Prevent Future Deaths
Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 1st July 2025, following the Inquest on the death of Jordanne Rose Roberts.
In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT).
“That unless and until the Trust is able to ensure that all locum doctors working at it’s hospitals have received training about the need to read both parts of a CT scan report, there remains a risk that (as in this case) life-threatening conditions may go undiagnosed and consequently that patients lives may be put at risk.”
In response to your specific concerns listed above please find below the actions the trust have taken:
- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)
In addition to this:
- The Trauma pathway is undergoing a huge change but is still in discussion phases that have not yet been made live.
- Adding an additional pop-up reminder at the point of raising the CT request will be added into the process under construction.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email:
Chair:
Acting Chief Executive:
The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Please let me know if you require any further information.
Re Regulation 28 Report to Prevent Future Deaths
Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 1st July 2025, following the Inquest on the death of Jordanne Rose Roberts.
In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT).
“That unless and until the Trust is able to ensure that all locum doctors working at it’s hospitals have received training about the need to read both parts of a CT scan report, there remains a risk that (as in this case) life-threatening conditions may go undiagnosed and consequently that patients lives may be put at risk.”
In response to your specific concerns listed above please find below the actions the trust have taken:
- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)
In addition to this:
- The Trauma pathway is undergoing a huge change but is still in discussion phases that have not yet been made live.
- Adding an additional pop-up reminder at the point of raising the CT request will be added into the process under construction.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email:
Chair:
Acting Chief Executive:
The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Please let me know if you require any further information.