Peter Ross

Dear Sir, Regulation 28 Report on the death of Peter Ross-Trust's Response Thank you for your Regulation 28 Report of 04 November 2022. In your Regulation 28 Report to Prevent Future Deaths dated 04 November 2022, you set out the following matters of concern:
1) A CT C-Spine requested on 08 July 2020 requested on the admission was mis- reported as normal.
2) Following that report, during the initial referral of Mr Ross to Neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross's cervical spine, made no note of his finding and did not escalate the finding to any other clinician.
3) Prior to burr- hole surgery, the Neurosurgical team did not review the CT C-Spine images.
4) Repeated failures in communication between Neurosurgical, Emergency Medicine, Nursing staff and Physiotherapists led to serious harm to Mr Ross.
5) Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross. In the opinion of HM Senior Coroner, action should be taken to prevent future deaths and he believes the Trust has the power to take such action. Trust's Response The Trust has carefully considered the concerns raised by HM Senior Coroner in his Regulation 28 Report and guidance has been sought from various specialists within the Trust as to the concerns raised by the Learned Coroner in his Regulation 28 Report. The Trust's response to the concerns is as follows;

1) The Trust fully accepts that the CT C- Spine requested on 08 July 2020 was mis- reported as normal. The Radiology Department 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 Ross's scans through its Governance process.
2) All Neurosurgical trainees have training in Advanced Trauma Life Support 'ATLS'. All substantive Consultants need Level IV competence in dealing with neuro-trauma. They are aware that appropriate precautions must be taken for protection of the neck for a head- injured patient. All doctors involved in trauma care will be supervised by Consultants with ATLS competence. Patients are systematically assessed. This involves taking a history, examining the patient, arranging and reviewing all appropriate investigations, and formulating a management plan. Departmental policy is that all patients referred to the Neurosurgery department have a named Responsible Consultant. The Consultant on call works with and supervises the rest of the on- call medical team. All admissions, operations, and treatment limiting decisions must involve the Consultant on call. In this case, the reviewing surgeon who received the referral for Mr Ross did look at the scans and did inform the Consultant of his concerns. The Consultant on call was therefore aware and made decisions on management. The neurosurgery department has reflected on this finding and will be providing training to all non-consultant grade clinical staff in authoritative reporting as well as support with techniques regarding empowerment and escalation to ensure that any future concerns are raised to the appropriate responsible consultant. This training will focus on resilience, good communication and empowerment to speak out or challenge areas of potential failings. The department will closely monitor training outcomes for success (at LFG and M&M meetings) and will implement formal training as part of local induction for new doctors.
3) The clerking (initial neurosurgical assessment upon admission) should have included C- spine assessment and the ATLS approach should have been followed. Spinal precautions should have been re- instated. The Neurosurgery Department has sent a reminder to all staff in Neurosurgery regarding the need to consider C-spine injury in a head- injured patient. The matter has also been discussed at the Departmental Clinical Governance meeting. The Neurosurgery Department intends to include a section on trauma and ATLS within its induction process. Mr Ross's case will also be presented at the Patient Safety Summit.
4) The department has reflected on this finding and is developing better communication methods with all stakeholders and colleagues. This includes inviting clinical colleagues to local M&M, MDT and Clinical Governance meetings to discuss cases that include multiple disciplines for learning and agreed action planning. MOT's are now in a hybrid format which incorporates virtual and face to face meetings offering flexibility for a wider range of stakeholder attendance.
5) The department recognise there were failures in the standard of medical record keeping for this case. The neurosurgical specialty has taken this very seriously and will undertake documentation audit on the trauma neurosurgical pathway. Routine refresher training will be made available as well as training during local induction for new staff. This includes

orientation of our records system. The Trust is currently in the process of implementing electronic patient record system. The purpose of the new system is to provide clinicians with an easier to access tool to aid good communication, decision making and clear patient planning. I would be happy to meet to discuss this response if that would be helpful to the Coroner.

Dear Mr Irvine,

Thank you for your Regulation 28 report to prevent future deaths dated 4 November 2022 about the death of Peter Mantador Ross. I am replying as Minister with responsibility for patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Peter Ross’ death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

The report raises concerns relating to: -
• The misreading of a CT C-spine on 8th July 2020
• Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’ CT, made no note of the finding and did not escalate to another clinician.
• Repeated communication failures between; neurological, emergency medicine. nursing staff and physiotherapist led to serious harm to Mr Ross.
• Clinical records were poorly maintained, exacerbating the lapse in communication between those treating Mr Ross

In October 2020 Barking, Havering & Redbridge NHS Trust (the Trust) conducted a serious incident report to look into concerns surrounding the death of Mr Ross. This report found a number of lessons could be learned; these include:

• All neck clearance should be adequately documented within the notes. A normal CT scan alone is not adequate for clearance of spinal injury and removal of spinal immobilisation.
• Advanced trauma life support documentation should be completed for all trauma calls and should include clear documentation of how C spine has been “Cleared”.
• As a good practice Neurosurgery teams should review all relevant CT images before surgery.

• Any suspicion of spinal injury even after initial assessment should prompt reinstatement of spinal immobilisation until the spine has been cleared by further imaging.
• Delay in appropriate spinal imaging may lead to potentially catastrophic harm to patients with suspected spinal injury.

In preparing this response, Departmental officials have made enquiries with the Care Quality Commission (CQC). CQC have engaged with the Trust and have discussed the specific areas of concern you have raised.

The Trust has provided assurance to CQC that this specific incident relating to Mr Ross 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.

As part of CQC’s regular engagement, CQC discussed with the Trust how they maintain oversight of implemented actions following the concerns you raised in your report, and how they ensure that learning about, and improvements to, safety and quality are sustained. The Trust stated to CQC they were in the process of reviewing these improvements, influenced by the introduction of Patient Safety Incident Response Framework and because they were making some staffing changes within clinical governance.

The CQC will continue to engage with the Trust and part of the focus of this engagement will be the review of the improvements the Trust has made.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Best Wishes,

MARIA CAULFIELD