“Spinal injuries are relatively uncommon but have the potential to cause significant…”
Dated 3 Jun 2015, from the coroner for Black Country. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 29 Jul 2015. A reply may have been sent and not yet published.
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.
- Report dated3 Jun 2015
- Deadline29 Jul 2015
- Published on judiciary.uk3 Jun 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Midlands Ambulance Service University NHS Foundation TrustNamed in the report as “West Midlands Ambulance Service NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| The Dudley Group NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Care Quality Commission | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
(1) Spinal injuries are relatively uncommon but have the potential to cause significant morbidity and mortality if not managed effectively. Mr White was an elderly patient who was at risk of falling and during the course of the inquest evidence emerged showing that he had sustained a traumatic injury of significant blunt force trauma. He also gave a descrip tion of feelings of numbness and lack of sensation in his legs and there was also a drop in blood pressure, which should have prompted a conservative approach in treating the patient by applying immobilisation on suspicion of spinal cord injury during his initial examination and assessment. (2) Evidence emerging from the inquest suggested that the initial failure to immobi se the patient then continued when he arrived at Hospita! and t e triage process failed to adequately assess the risk again it appears the triage pr cess is ieav y rel ant upo ‘i the ha dover f om t e paramedic crew withou, urther and detailed assessment. (3) It wasn. 1 unti five hours after the nital fail that a suspected spinal cord injury yes diagnosed, (4) 6 n ight of the nquest findings, you may consider that the guidelines and policy n the assessment and management of actual and potenti al spinal injuries my need o be exan’ined
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, 2015-0212
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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