Patient died after locum missed extra scan report

A hospital trust has been told to urgently improve training for temporary staff after the death of a patient sent home before her full scan results were read.

An inquest concluded Jordanne Rose Roberts, 23, from Kidderminster, died from an undiagnosed pulmonary embolism, with neglect contributing to her death.

A locum doctor at Alexandra Hospital, Redditch discharged her last August without waiting to read the second half of a CT scan report, which identified the blood clot.

After being warned by the county's senior coroner of the risk of further deaths, Worcestershire Acute Hospital NHS Trust apologised, and said it had made changes.

Ms Roberts was assessed in the emergency department of the hospital on 10 August 2024, after falling down stairs at home.

The locum doctor on duty - the most senior doctor on duty in A&E that day - did not know her CT scan results would be reported in two parts.

She was discharged on the basis of the first half of the report, which did not mention a blood clot.

The patient collapsed at home on 12 August, and died a short time later.

The first CT report did made clear a second report was to follow, coroner David Reid's prevention of future deaths report said.

Her death would probably have been prevented if the pulmonary embolism had been identified and treated in hospital, he added.

According to the report, although the trust confirmed employed doctors were trained to read both parts of CT scan reports, it could not say whether steps had been taken to ensure all locum doctors received the equivalent training.

Temporary staff were invited to education sessions covering the topic, but no record was kept about whether they attended.

Unless and until the trust was able to ensure all locum doctors at its hospitals were trained about the need to read the reports in full, there remained a risk "life-threatening conditions may go undiagnosed" and "patients' lives may be put at risk", the coroner said.

"I would like to repeat our sincere and unreserved apologies to Jordanne's family for the failures in the care she received from us," said the NHS trust's chief medical officer Dr Jules Walton.

A thorough review of what went wrong had been carried out, with a series of actions taken as a result, she added.

"Those actions include measures to make sure that all medical staff, including temporary staff, are aware of our processes for reporting scan results," Dr Walton said.

The trust must respond to the coroner's report in detail within 56 days.

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