Recurring concern

Failure to obtain clinically indicated spinal imaging before treatment

First to latest report 2 Oct 2019 — 26 Nov 2019

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures to obtain, arrange or appropriately consider clinically indicated spinal imaging before or during initial treatment, including cervical-spine imaging when suspected spinal injury, neck pain, distracting injury or comparable indicators require it.

What is not included
  • Excludes imaging performed after treatment when the concern is only delayed review or interpretation rather than failure to obtain indicated pre-treatment spinal imaging.
  • Excludes non-spinal diagnostic imaging, including chest, abdominal, cardiac and lower-limb imaging, unless the assertion explicitly concerns spinal imaging.
  • Excludes generic clinical assessment, staffing, documentation or communication deficiencies unless they directly result in omitted or inadequate spinal imaging.
  • Excludes failures to immobilise or otherwise manage suspected spinal cord injury when spinal imaging is not the deficient control.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North Yorkshire and City of York

    AI-generated summary

    John Thomas Lawler · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Thomas Lawler suffered a fractured neck and spinal cord damage during chiropractic spinal adjustment and subsequent mobilisation on 11 August 2017. He died from respiratory depression caused by the traumatic spinal cord injury on 12 August 2017. Concerns included the absence of pre-treatment spinal imaging and mobilisation after he reported loss of sensation in his arms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of pre-treatment spinal imaging

    Wider context from the report

    “(1) No pre-treatment images were taken of Mr Lawler's spine. Ossification of the spine was not known until post-trauma CT images were obtained. ”

    Source location

    John Thomas Lawler · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. West Sussex

    AI-generated summary

    Richard Lester Ridout · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Richard Lester Ridout was involved in a single-vehicle road traffic collision on 20 January 2019 and was later readmitted with respiratory failure, where cervical fractures and pulmonary contusions were discovered. The inquest concluded that he died from Influenza A and streptococcal pneumonia causing sepsis and multiple organ failure. Concerns were raised that the assessment and escalation of treatment after the collision did not include a trauma call, trauma CT scan, or cervical spine imaging despite the reported collision circumstances, injuries, neck pain and medication use.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out cervical spine imaging after distracting injury and neck pain

    Wider context from the report

    “(3) There was evidence available to the medical staff involved in his treatment that Richard had consumed diazepam and buprenorphine prior to his arrival at hospital. Despite this information being available, the distracting injury to his shoulder and a complaint of neck pain no imaging of his c-spine was carried out. ”

    Source location

    Richard Lester Ridout · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a fractured-scapula management protocol advising cervical-spine and chest X-rays and a lower threshold for clinically indicated CT scanning.

    Verbatim wording from the response

    “While there was no clear clinical indication for a full trauma CT scan on this occasion, we are currently developing a protocol for the management of patients who have sustained a fractured scapula. The protocol will advise that these patients should now have x-rays of their cervical spine and chest, with a lower threshold to perform a CT scan if clinically indicated. The work on protocols is taking place across the two hospital sites and will be complete within 3 months.”

    Source location

    2019-0331-Response-by-Western-Sussex-Hospitals
    Page 1 · response
    Published 8 November 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026