“Having had a CT scan at Birmingham Heartlands Hospital on 14th June 2023, James 5 Pearson…”

The coroner’s concerns

– 1. Having had a CT scan at Birmingham Heartlands Hospital on 14th June 2023, James 5 Pearson was diagnosed with severe pelvic injuries, and the Radiologist reported findings which were consistent with an active pelvic bleed. 2. At 03.16, observations were taken, and the Doctor was satisfied that James was maintaining his blood pressure and therefore was not actively bleeding at that time. 3. During the inquest, I heard that James was attached to a monitor, which was taking his observations every 15 minutes. None of these observations, however, were documented. This is of concern, as it is not possible to know at what point James began to decline. I am concerned that lack of proper documented observations could lead to future deaths, as staff will not be able to follow the observation pattern and notice a decline in presentation. 4. At 04.20am, James became more agitated and nurses noted a drop in consciousness. At this point the Major Haemorrhage Protocol was activated at 04.23am, as there was now a suspicion of ongoing bleeding. 5. Whilst waiting for his blood products, James suffered a cardiac arrest at 04.25am 6. told me in evidence that during the time since his last review by a Doctor at 03.16am, and his cardiac arrest at 04.25am, James was not seen by a Doctor, and only Nurses were available in the department. The only Doctor on shift at that time was dealing with another very unwell patient, who also required resuscitation. 7. told me that at the point in time the deterioration in James was noted, sometime between 04.00-04.20am, James should have received fluids, and in his opinion, if he had done so, on the balance of probabilities, he would not have had a cardiac arrest. He added that this was beyond what he would expect a nurse to adduce, however, if the Doctor had been present, he believed this would have been done. 8. I am therefore concerned that there were not enough Doctors in the department at the time, meaning that there is no resilience to deal effectively with more than one very unwell patient at any given time. If this is not addressed, there is a risk of future deaths. 9. I further heard from that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths.

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, 2024-0266

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