Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0109, written 25 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2025 |
|---|---|
| Reference | 2025-0109 |
| Deceased | Khadija Kerri |
| Coroner | Louise Slater |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
, CORONER'S COURT AND OFFICE re) CROWN COURT “td COLLEGE ROAD DONCASTER DN1 3HS MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: nee | Tel: (01302) 737135 / Fax. (01302) 736365 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 10: EEE Chief Executive, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust 1. CORONER | am Louise Slater, Area Coroner for South Yorkshire (East) District 2. CORONER'S LEGAL POWERS | 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. htto:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 5 July 2024 | commenced an investigation into the death of Khadija Kerri. The investigation concluded at the end of the inquest with a Narrative conclusion of: Khadija Kerri died primarily as a result of heart disease, but her death occurred on a background of traumatic injuries sustained in an unwitnessed fall and other co-morbidities. . The medical cause of death : 1a Acute Coronary Event 1b Ischaemic Heart Disease, Cardiomegaly, Left Ventricular Hypertrophy 1c ll Fall, Multiple Fractures, Dementia, Type II Diabetes Mellitus 4, CIRCUMSTANCES OF THE DEATH Khadija Kerri was admitted to Doncaster Royal Infirmary on the 19th June 2024 with a head laceration and multiple traumatic injuries following an unwitnessed fall downstairs at her home. CT scans were undertaken and reported by Everlight Radiology (a remote third party). These scan were reported on the 19th June 2024. Following a routine peer review the next day, a discrepancy in radiological report was identified and the original CT report had missed two cervical fractures and a rib fracture. An addendum report was issued and a telephone call made to Doncaster Royal Infirmary to advised of the new findings. Despite the addendum report being uploaded on the shared system and a telephone call being made to the Emergency Department at Doncaster Royal Infirmary on the evening of the 20th June 2024, this information was not communicated to or acted acted upon by the clinical team caring for Ms Kerri until the 23rd June 2024. Following the full extent of her injuries being identified, the fractures were immobilised. Ms Kerri remained in hospital until her death on the 3rd July 2024. The third party provider identified the missed fractures within 24 hours and communicated this to Doncaster Royal Infirmary, however, this was not acted upon until the 23rd June 2024 due to there being no clear internal policy of disseminating an addendum report and/or it contents to the treating team. This lead to a delay in appropriate care. 5. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances itis my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - 1. There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team. If this is not addressed there is potential for similar delays and incorrect management of patient care. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you HB 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 Tuesday 22nd April 2025. 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: HE, Khadija's daughter. | have also sent it to oT Secretary of State for Health and Social Care and Everlight Radiology who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. 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. 25 February 2025 KOO Mrs S L Slater, Area Coroner for South Yorkshire East
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
, Interim Executive Medical Director , Medical Director – Operations , Interim Medical Director - Workforce , Associate Medical Director – Clinical Safety , Associate Medical Director – Professional Standards , Clinical Governance & Professional Standards Co-ordinator (642149) 20 May 2025 STRICTLY CONFIDENTIAL – ADDRESSEE ONLY Mrs S L Slater Area Coroner for South Yorkshire East Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Mrs Slater Khadija Kerri (deceased) I write to you with respect to the Regulations 28 Report originally issued on the 25 February 2025 to the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of Khadija Kerri concluded on the 5 July 2024. I understand that your initial notification was inadvertently missed; for which we extend our sincere apologies, and a follow up call to your office confirmed that the submission date of our response would be extended to 29 May 2025. The report was received by the Chief Executive’s office and forwarded to me in order to provide a response. I have been assisted in constructing this response by , Head of Service in Radiology. Safety and , Associate Medical Director for Clinical I would respond to the matters of concern referred to within the PFDR as follows: 1. There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team. If this is not addressed there is potential for similar delays and incorrect management of patient care I would like to take this opportunity of assuring you and Ms Kerri’s family that the Trust has undertaken a full review of the Failsafe Alert for Radiological Findings (Communication Protocol) PAT/T 38 v.5 and this is scheduled to be duly approved through the Local Clinical Governance processes by the 4 June 2025. Our Radiology department communicated with Everlight Radiology to ensure their full agreement with amendments. The Protocol has been placed on the Trust’s Patient Safety Review Group agenda scheduled for 6 June 2025 for ratification. Once fully approved and ratified, the protocol will be uploaded onto the Trust’s intranet within the Policies & Procedures section which is accessible by all staff. It is important to note this is a Trust-wide Policy which provides further enhancement to the safety of our patients on all hospital sites. A key amendment to the Failsafe Protocol addresses your concern in terms of the Radiology Departmental procedures for communication of failsafe alerts. The procedure clearly defines that “out of hours” (tele- radiology reported) critical findings will be telephoned directly from the tele-radiology reporting radiologist directly to the referrer on site (“responsible person”) and a record of the conversation will be added as an addendum to the report issued. In accordance with the Trust’s approved policy procedure, the Failsafe protocol will be audited within 3 months of implementation to ensure all “Failsafe notifications” are communicated and managed appropriately. Whilst it is recognised that this revision is essential to ensure patient safety, it is acknowledged that the safety net contained within the protocol does not replace the Referrer’s responsibility to read and act upon radiology reports. This is in line with national guidance “Recommendations on Alerts and Notification of Imaging Reports”, published by the Academy of Medical Royal Colleges October 2022. This clinical responsibility will be further highlighted through Trust communications and it is the Trust’s responsibility to ensure this is actively communicated on a regular basis through governance processes. I trust that this will reassure you that the communication alert processes contained with the revised protocol provides an enhanced safety net to undoubtedly make it safer for patients. Yours sincerely Acting Executive Medical Director Cc: , Chief Executive , Associate Medical Director for Clinical Safety , Head of Service, Radiology , Trust solicitor
See every Prevention of Future Deaths report matching Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.