Richard Lester Ridout · Prevention of Future Deaths report

On the 22nd February 2019 an investigation was opened into the death of Richard Lester Ridout, aged 43. The investigation concluded at the end of the inquest on 26th September 2019. The conclusion of the inquest was that ‘Richard Lester Ridout died as a result of Influenza A and streptococcal pneumonia causing sepsis which lead to multiple organ failure.’

On the 20th January 2019 Richard Ridout was involved in a single vehicle road traffic collision. His vehicle left the road and rolled over. Richard Ridout extricated himself from the vehicle after paramedics arrived. He was complaining of a pain in his shoulder and did not report any additional pain upon c-spine palpation. He reported that he had consumed 40mg diazepam and 8mg Buprenorphine. He stated to the ambulance staff that he had been travelling at 30 mph.
On arrival at St Richard’s Hospital he was diagnosed with a fractured scapula. He complained of both neck and shoulder pain. A chest and pelvic x-ray were ordered but Richard declined the latter. He declined a full trauma examination. No additional pain was reported on c-spine palpation. He informed the junior doctor that he had been travelling at 50-60mph.
His c-spine was not imaged, a trauma series CT was not requested and a trauma call was not put out.
On the 29th January 2019 Richard was readmitted to hospital and transferred to St Guy’s & Thames’ due to respiratory failure. Fractures of his C7 and C5 vertebrae were discovered along with pulmonary contusions. He was in septic shock and contracted the infections noted above.
I found that the fractures had been caused by the road traffic collision on the 20th January 2019.

(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out.
(2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC.
(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.
(4) Whilst the undiagnosed condition did not contribute to Richard Ridouts death I am concerned that the failure to escalate the assessment and treatment of a person involved in such a road traffic collision could lead to deaths in the future.