John Thomas Cleave · Prevention of Future Deaths report

On 8 January 2024 an investigation was commenced into the death of John Thomas Cleave aged 70 years old.

The medical cause of death was;

1a Aspiration Pneumonia
b Fall and Cervical Spine Fracture

2 Ankylosing Spondylitis

In answer to the how, when and where questions I recorded:

John Thomas Cleave died at 1800 on 29 December 2023 at Torbay Hospital as a result of complications from a cervical spine fracture sustained in an unwitnessed fall whilst the Deceased was at his allotment at around 1700 the previous day against a background of ankylosing spondylitis. The management of the Deceased's treatment at hospital was compromised by the radiological report of a CT-Scan failing to identify a high suspicion of a haemothorax and the Deceased's care not being led and directed by a clinician with appropriate experience for the complexity of the case. Care should have been transferred to the nearest major trauma centre at Derriford Hospital in Plymouth.

Conclusion

Accidental Death

At about 1700 on 28 December 2023 John Thomas Cleave sustained a fracture to his cervical spine and a probable haemothorax as a result of an unwitnessed fall on his allotment. The Deceased’s injuries and subsequent treatment were complicated significantly by the fact that he suffered from the spinal condition ankylosing spondylitis and had previously undergone spinal fusions and suffered a cervical fracture.
The Deceased was admitted to Torbay hospital Torquay at around 1930 and underwent a CT-Scan at around 2200. An initial view of the scan by the clinicians in the Emergency Department identified an unstable fracture of the cervical spine and a suspected haemothorax. A plan was made for the nearest major trauma centre in Plymouth to be contacted with a view to transferring the Deceased’s care. Before the major trauma centre was contacted, at around 2300 the scan was reported by a registrar grade radiologist, who discounted any haemothorax. At the time of submitting the report there was no consultant radiologist on call to review the report. A consultant radiologist has recently reviewed the scan and indicated that it should have been reported as identifying a high suspicion of haemothorax.
It is likely that the report wrongly discounting the haemothorax influenced the treatment plan for the Deceased and contributed to his not being transferred appropriately to the major trauma centre for treatment.
The next day, the Deceased’s care had been transferred to the Trauma and Orthopaedic Team, albeit his remaining in the emergency department . At approximately 1300 the Deceased was seen to vomit, aspirate and go into cardiac arrest. Whilst he was successfully resuscitated, his condition deteriorated and he died at 1800 on 29 December 2023 at Torbay Hospital.
In the light of the injuries which the Deceased suffered on a background of a complex medical history involving his spine and chest, he should have been transferred to the major trauma centre at Plymouth as soon as the extent of his injuries and his previous medical history became known.
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During the course of the inquest, evidence was given to me that a level of complexity due to the Deceased’s medical history, his injuries and an apparent artifact in the CT-Scan caused by metalwork in the Deceased’s spine from previous surgery required the expertise of a consultant radiologist. I was informed that there was (and is still) no out of hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay.

I am concerned that there will be from time to time a need for scans and x-rays to be considered and interpreted at consultant radiologist level to facilitate urgent treatment and there is at present a gap in such cover which puts patients at risk.