A REPORT has recommended doctors employed by the Worcestershire Acute Hospital NHS Trust receive training relating to CT scan reports after a woman died because of an undiagnosed pulmonary embolism.
An inquest into the death of Jordanne Roberts found a locum doctor discharged her home as only one part of a two-part CT scan had been read.
On August 10 last year, Jordanne was assessed at the Emergency Department at the Alexandra Hospital in Redditch after falling down stairs at her Kidderminster home.
The locum doctor who discharged her had not waited to read a full CT scan report which identified she had a pulmonary embolism.
On the morning of August 12, Jordanne collapsed and died a short time later. A post mortem examination confirmed the cause of death to be a pulmonary embolism.
The report stated her death ‘would probably have been prevented if the pulmonary embolism had been identified and treated in hospital’.
The coroner expressed concerns and said there was a risk future deaths would occur unless action was taken.
The report stated: “Jordanne’s death arose because a locum doctor, said to be the most senior doctor on duty in the Emergency Department on August 10, 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.”
It was recommended that all of the trust’s own employed doctors receive training so they ensure both parts of any CT scan report are read.
It also recommended all new locum doctors working for the trust be provided with an induction pack, which highlighted the requirement to read both parts of any CT scan report.
It was unconfirmed that steps had been taken to ensure all locum doctors already working at the trust had received the equivalent training.
It was indicated they had been invited to attend education sessions in which this topic has been covered, but no record was kept of whether those doctors did attend.
The coroner wrote: “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) life- threatening conditions may go undiagnosed and consequently patients’ lives may be put at risk.”
The trust was told it must respond to the report within 56 days of the report – by August 21.
Dr Jules Walton, Chief Medical Officer for Worcestershire Acute Hospitals NHS Trust, said: “On behalf of our trust I would like to repeat our sincere and unreserved apologies to Jordanne’s family for the failures in the care she received from us.
“We have carried out a thorough review of what went wrong in Jordanne’s case, and we have taken a series of actions as a result.
“Those actions include measures to make sure that all medical staff, including temporary staff, are aware of our processes for reporting scan results.”
