Jordanne Rose ROBERTS · Prevention of Future Deaths report

On 3 September 2024 I commenced an investigation and opened an inquest into the death of Jordanne Rose ROBERTS. The investigation concluded at the end of the inquest on 25 June 2025.

The conclusion of the inquest was that Jordanne “died from an undiagnosed pulmonary embolism. Her death was contributed to by neglect”.

In answer to the questions “when, where and how did Jordanne come by her death?”, I recorded as follows:

“On 10.8.24 Jordanne Roberts was assessed in the Emergency Department of the Alexandra Hospital, Redditch after falling down stairs at her home in Kidderminster. The locum doctor who assessed her discharged her home without waiting to read a full CT scan report, which identified that she had a pulmonary embolism. On the morning of 12.8.24 Jordanne collapsed suddenly at home, and died a short time later. A post mortem examination confirmed the cause of death to be a pulmonary embolism. Her death would probably have been prevented if the pulmonary embolism had been identified and treated in hospital.”

1) Jordanne’s death arose because a locum doctor, said to be the most senior doctor on duty in the Emergency Department on 10.8.24, did not know that her CT scan taken that day would be reported in two parts. The initial report did not mention the presence of a pulmonary embolism, but did make clear that a second and final report was to follow. The doctor proceeded to make the decision to discharge Jordanne without reading the second and final report, which highlighted the pulmonary embolism;

2) In her evidence at inquest, ████████ ( Head of Patient Safety at the Trust ) confirmed:
(a) that all of the Trust’s own employed doctors receive training so that they ensure that both parts of any CT scan report are read;
(b) that all new locum doctors working for the Trust are provided with an induction pack, which highlights the requirement to read both parts of any CT scan report.
However, ████████ was unable to confirm that steps have been taken to ensure that all locum doctors already working at the Trust have received the equivalent training. She indicated that they have been invited to attend education sessions in which this topic has been covered, but that no record is kept of whether those doctors did in fact attend.

I am therefore concerned that unless and until the Trust is able to ensure that all locum doctors working at its hospitals have received training about the need to read both parts of a CT scan report, there remains a risk that ( as in this case ) life-threatening conditions may go undiagnosed, and consequently that patients’ lives may be put at risk.