Peter Ross

Private & Confidential 

Mr G  Irvine 
HM  Senior Coroner 
Walthamstow Coroner's Court 
Queens Road 
London 
E17 8QP 

r4'1:kj 

Barking,  Havering and  Redbridge 
University Hospitals 
NHS  Trust 

Legal  Services 
Queen 's Hospital 
Rom  Valley Way,  Romford,  RM?  0AG 

www.bhrhospitals.nhs.uk 
"#  @BHRUT _NHS 

03 January 2023 

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. 

Yours sincerely, 

Chief Executive

From Maria Caulfield  
Minister of State for Mental Health and Women’s Health Strategy 

39 Victoria Street 
London 
SW1H 0EU 

Mr Graeme Irvine 
East London Coroners 
Queens Road Walthamstow 
E17 8QP 

Dear Mr Irvine, 

13 May 2024 

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. 

1 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 •  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