Peter Mantador Ross · Prevention of Future Deaths report

On 7th January 2022 this Court commenced an investigation into the death of Peter Mantador Ross, age 70 years. The investigation concluded at the end of the inquest on 11th October 2022. The conclusion of the inquest a narrative conclusion incorporating a finding of neglect;

Narrative Conclusion

On 8th July 2020 Mr Peter Mantador Ross sustained a fall down stairs at home. In the course of that fall he sustained a subdural haemorrhage and a cervical spine fracture.

Mr Ross’s neck was immobilised by paramedics and he was taken to hospital by ambulance where he underwent diagnostic tests.

CT images were misinterpreted which resulted in the spinal fracture remaining undiagnosed.

An undocumented decision was made to cease immobilisation of Mr Ross’s spine.

A concern was later raised that Mr Ross had in fact sustained a spinal injury, an urgent MRI scan was requested. No order was given to recommence immobilisation of the spine pending MRI.

The urgent MRI was delayed for two days. The lack of spinal immobilisation after renewed suspicion of spinal injury contributed to a subsequent cardiac arrest, tetraplegia and tetraparesis.

On 19th October 2021 Mr Ross suffered an episode of aspiration made more likely by his injuries. As a result of that aspiration he developed pneumonia which caused his death.

Neglect contributed to Mr Ross’s death ”

Mr Ross’s medical cause of death was determined as;

1a Broncho-pneumonia
b Cervical spine fracture and injury (2020)
c
II Cardiac failure

See narrative above

1. A CT C-spine requested on the admission on 8 July 2020 was misreported 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 CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.

1. A CT C-spine requested on the admission on 8 July 2020 was misreported 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 CT Spine, made no note of his finding and did not escalate his 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.