Sara Jones

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 

1 

 Betsi Cadwaladr University Health Board 

1  CORONER 

I am Duncan RITCHIE, H M Assistant Coroner for the coroner area of Stoke-on-Trent and 
North Staffordshire 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 10 March 2022 I commenced an investigation into the death of Sara Anest JONES aged 
25.  The investigation concluded at the end of the inquest on 07 March 2023.  The 
conclusion of the inquest was that: 

Sara Anest Jones died at the Royal Stoke University Hospital, Stoke-on-Trent on 2nd April 
2021 of complications of a bowel injury sustained in a road traffic collision on 30th March 
2021.  Miss Jones was treated for her injuries at the Royal Stoke University Hospital, Stoke-
on-Trent.  Those responsible for Miss Jones' care at the Royal Stoke University Hospital did 
not identify that she had sustained a bowel injury and consequently it remained untreated. 
Miss Jones developed peritonitis because of the untreated bowel injury, from which she 
later died. 

4  CIRCUMSTANCES OF THE DEATH 

Road traffic collision contributed to by neglect 

5  CORONER’S CONCERNS 

During the course of the investigation my inquiries revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths could occur unless action is taken.  In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th 
March 2021.  The deceased was then transferred to the Royal Stoke University Hospital, 
Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was 
available.  Because of this the patient was transferred without the radiologist's report.  The 
radiologist's report became available shortly before 1:00am on 31st March 2021, but was 
not sent to the Royal Stoke University Hospital until 5:35am that day.  It was not clear that 
safe receipt of the report in Stoke-on-Trent was ever confirmed.  Doctors in Stoke-on-Trent 
then failed to follow up on signs of a possible bowel injury which were indicated in the 
radiologist's report on the CT scan. 

During the inquest I was told that the circumstances of this case were unusual and that 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 there was not a protocol in place to ensure the prompt and secure delivery of radiology 
reports in circumstances like this. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or 
your organisation) have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by May 09, 2023.  I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the 
timetable for action.  Otherwise you must explain why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: 

1. The family of Sara Jones 

2. The Royal Stoke University Hospital 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it useful or 
of interest. 

The Chief Coroner may publish either or both in a complete or redacted or summary form. 
He may send a copy of this report to any person who he believes may find it useful or of 
interest. 

You may make representations to me, the coroner, at the time of your response about the 
release or the publication of your response by the Chief Coroner. 

9  Dated: 15/03/2023 

Duncan RITCHIE 
H M Assistant Coroner for 
Stoke-on-Trent and North Staffordshire 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Duncan Ritchie 
HM Assistant Coroner 
Stoke-on-Trent and North Staffordshire  
Civic Centre 
Glebe Street 
Stoke-on-Trent ST4 1HH 

Dyddiad / Date: 03 May 2023 

Dear Mr Ritchie,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Sara Anest Jones  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 15 March 
2023,  issued  by  yourself  to  Betsi  Cadwaladr  University  Health  Board,  following  the 
inquest touching the death of Sara Anest Jones.  

I would like to begin by offering my deepest condolences to the family and friends of Ms 
Jones. 

In  the  Notice,  you  highlighted  concerns  regarding  the  prompt  and  secure  delivery  of 
radiology reports from our hospitals to our external major trauma tertiary centre, the Royal 
Stoke  University  Hospital.  I  note  that  the  University  Hospitals  of  North  Midlands  NHS 
Trust, as joint parties to the Notice, will also respond to you. 

We have carefully considered the inquest findings and your Notice, and in response our 
Emergency Department Clinical Lead has taken forward improvement work. This work 
has been done alongside our own Radiology Department and our partners at the Royal 
Stoke University Hospital.  

We have now established a process that if a patient leaves our emergency departments 
without  a  report,  which  is  very  rare,  then  the  report  will  be  sent  by  email  and  its  safe 
receipt will be confirmed by telephone.  

This process  is being  included  in our  major trauma  standard  operating  procedure and 
checklists  by  the end of  May  2023  by  our  Trauma  Network Manager.  This will ensure 
staff are clear on the actions they need to take. 

All trauma transfers are discussed and reviewed at our Trauma Group, so this group will 
have oversight of this new procedure and will ensure this this new process is subject to 
ongoing audit to give assurance.  

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Once again, I offer my deepest  condolences to the family and friends of  Ms Jones for 
their loss.  

I  hope  our response  offers you  assurance  that  we  have  learned from  the  inquest  and 
made  changes  to  our  ways  of  working.  Should  you  require  any  further  information  or 
assurance we would be happy to provide.  

Yours sincerely 

Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro 
Executive Medical Director / Acting Deputy Chief Executive  

cc 

 Deputy Director of Quality

Executive Suite 
Trust Headquarters 
Springfield 
City General Site 
Newcastle Road 
Stoke on Trent 
ST4 6QG 

5 May 2023 

STRICTLY PRIVATE & CONFIDENTIAL 
Mr D Ritchie  
H M Assistant Coroner  
Stoke on Trent and North Staffordshire 

Dear Mr Ritchie 

Sara Anest JONES  

Further  to  my  letter  dated  16  March  2023,  I  am  pleased  to  provide  a  response  to  your  report  under 
paragraph  7  of  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the 
Coroners  (Investigations)  Regulations  2013,  addressing  your  concerns  surrounding  the  death  of  Sara 
Anest Jones.  

Recorded Circumstances of the Death 
Sara  Anest  Jones  died  at  the  Royal  Stoke  University  Hospital,  Stoke  on  Trent  on  2  April  2021  of 
complications  of  a  bowel  injury  sustained  in  a  road  traffic  collision  on  30  March  2021.  Miss  Jones  was 
treated for her injuries at the Royal Stoke University Hospital, Stoke on Trent. Those responsible for Miss 
Jones’  care  at  the  Royal  Stoke  Hospital  did  not  identify  that  she  had  sustained  a  bowel  injury  and 
consequently  it  remained  untreated.  Miss  Jones  developed  peritonitis  because  of  the  untreated  bowel 
injury, from which she later died. 

Concerns 
During the course of the  inquest you felt that evidence revealed matters giving rise for concern. In your 
opinion, matters for concern are as follows: 

1.  The  patient  was  admitted  to  Royal  Stoke  University  Hospital,  Stoke  on  Trent  as  a  “polytrauma” 
patient  who  had  sustained  serious  injuries  in  a  road  traffic  collision.  Following  her  admission,  she 
was  treated  by  doctors  from  several  different  specialisms,  but  it  was  apparent  that  some  doctors 
involved  in  her  care  concentrated  on  only  the  injuries  that  fell  within  their  speciality  and  did  not 
consider the patient as a whole. At an important stage in her treatment the general surgeons thought 
that  the  orthopaedic  surgeons  would  alert  them  to  any  intervention  which  was  needed  from  their 
speciality,  whilst  the  orthopaedic  surgeons  expected  the  general  surgeons  to  regularly  review  the 
patient. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
    
 
 
 
 
 
 
 
 
 
 
 Partly as a result of the doctors concentrating only on the injuries which fell into their speciality signs 
of a bowel injury which the patient sustained were missed. The patient subsequently died as a result 
of complications of the undiagnosed bowel injury. 

Evidence  was  given  during  the  inquest  that  a  major  trauma  consultant  role  was  in  the  process  of 
being developed at the Royal Stoke University Hospital, Stoke on Trent to address issues like this, 
but that the role was only 50% filled at the current time. 

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  

Action Taken 
The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest 
of Sara Jones seriously and indeed, I am grateful that you have raised your concerns. 

1.  At the time of the inquest the Court heard that the current trauma rota was 50% filled and that the 
Trust were seeking to appoint further consultant cover so that all trauma patients are reviewed by a 
trauma consultant within 24 hours of their admission. In order to progress this, the Trust requires a 
further 6 consultants to be included on the rota.  

In  order  to  fulfil  this,  an  internal  recruitment  process  has  already  been  initiated.    One  additional 
consultant is now in post, and negotiations are underway with a further three consultants which will 
fill  our  Monday-Friday  rota.    We  intend  to  have  this  rota  staffed  by  the  beginning  of  August  2023.  
Approval  for  the  development  of  a  business  case  is  under  consideration  for  the  expansion  of  the 
Major  Trauma  service,  to  include  weekend  and  out  of  hours  cover.    We  intend  to  remove  any 
potential  confusion  around  team  responsibilities  by  redefining  the  Major  Trauma  Service.  This  will 
mean that the Major Trauma Consultant is primarily responsible for the whole patient review and will 
liaise  with  specialty  teams  as  appropriate.    The  timescale  for  this  redesign  is  within  the  next  12 
months.  

I do hope that the above information provided assurance that the Trust has taken the concerns raised at 
the inquest seriously. 

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. 

Yours sincerely 

CHIEF EXECUTIVE