“Jordanne’s death arose because a locum doctor, said to be the most senior doctor on duty…”
Dated 26 Jun 2025, from the coroner for Worcestershire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Aug 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated26 Jun 2025
- Deadline21 Aug 2025
- Published on judiciary.uk14 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Worcestershire Acute Hospitals NHS TrustNamed in the report as “Worcestershire Acute Hospital NHS Trust” | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
– 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; 1 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 ) lifethreatening conditions may go undiagnosed, and consequently that patients’ lives may be put at risk.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0326
- Added to Minute Book
- 8 Oct 2026
- Reuse
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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