John Cleave

On 8 January 2024 an investigation was commenced into the death of John Thomas Cleave aged 70 years old. 

The medical cause of death was; 1a Aspiration Pneumonia     b Fall and Cervical Spine Fracture 2 Ankolosing Spondylitis  

In answer to the how, when and where questions I recorded; John Thomas Cleave died at 1800 on 29 December 2023 at Torbay Hospital as a result of  complications from a cervical spine fracture sustained in an unwitnessed fall whilst the  Deceased was at his allotment at around 1700 the previous day against a background of  ankolosing spondylitis. The management of the Deceased’s treatment at hospital was  compromised by the radiological report of a CT-Scan failing to identify a high suspicion of a  haemothorax and the Deceased’s care not being led and directed by a clinician with  appropriate experience for the complexity of the case. Care should have been transferred to the nearest major trauma centre at Derriford Hospital in Plymouth.  

Conclusion Accidental Death

At about 1700 on 28 December 2023 John Thomas Cleave sustained a fracture to his cervical  spine and a probable haemothorax as a result of an unwitnessed fall on his allotment. The  Deceased’s injuries and subsequent treatment were complicated significantly by the fact that  he suffered from the spinal condition ankolosing spondylitis and had previously undergone  spinal fusions and suffered a cervical fracture.  

The Deceased was admitted to Torbay hospital Torquay at around 1930 and underwent a CT-Scan at around 2200. An initial view of the scan by the clinicians in the Emergency Department identified an unstable fracture of the cervical spine and a suspected haemothorax. A plan was made for the nearest major trauma centre in Plymouth to be contacted with a view  to transferring the Deceased’s care. Before the major trauma centre was contacted, at around  2300 the scan was reported by a registrar grade radiologist, who discounted any  haemothorax. At the time of submitting the report there was no consultant radiologist on call to review the report. A consultant radiologist has recently reviewed the scan and indicated that it  should have been reported as identifying a high suspicion of haemothorax.  

It is likely that the report wrongly discounting the haemothorax influenced the treatment plan for the Deceased and contributed to his not being transferred appropriately to the major trauma centre for treatment.  

The next day, the Deceased’s care had been transferred to the Trauma and Orthopaedic   Team, albeit his remaining in the emergency department . At approximately 1300 the  Deceased was seen to vomit, aspirate and go into cardiac arrest. Whilst he was successfully  resuscitated, his condition deteriorated and he died at 1800 on 29 December 2023 at Torbay  Hospital.  

In the light of the injuries which the Deceased suffered on a background of a complex medical  history involving his spine and chest, he should have been transferred to the major trauma  centre at Plymouth as soon as the extent of his injuries and his previous medical history, became known.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe that you have the power to take such action.