“. 1.A CT C-spine requested on the admission on 8 July 2020 was misreported as normal”
Dated 4 Nov 2022, from the coroner for East London. Sent to 2 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
All responses publishedReplies were due by 30 Dec 2022.
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 dated4 Nov 2022
- Deadline30 Dec 2022
- Published on judiciary.uk7 Nov 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS TrustNamed in the report as “Barking, Havering and Redbridge NHS Trust” | Response publishedPublished on judiciary.uk in November 2022. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in November 2022. |
The coroner’s concerns
. 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 Julv 2020 was misreported as 2 normal. 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. 2.
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, 2022-0354
- Added to Minute Book
- 8 Oct 2026
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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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