During the COLIgE ofthe inques: lhe evidence revealed matters Jving ! S8 tO concer; In my Cpinicn there ts 3 risk that fulure deaths will occur unless acticn is Iaken: In the ciicumstances i Is My statutory duty Io repott to YQV_ The MATTERS OF CONCERN ara as follows (1} There were a number of citicullies witn communicaton between the varou8 c iriciars and hospital Trust_ This led I3 a initial transler cf the paten: a delay in his subsequent review by a serior ciinician and ccniysion on the part cf nursirg stafi 35 t3 whother Mr Calanach was to be keplnil by mouth ardiar gven his prescribed modication; While Iiis J matter fur You itmay bethat Ine Trust will wantto reilect on whetner tnere i5 3 nj8d tc standard ze its inter hcspital transier process 5o [nat nursing a5 well as medical staff are fully engaged with the FTCzess (2) Additonal concerns over comminicalon were identifed with clear instrustions Irom Consullants not beinj carred out: In particular, an instructjn !o have tne daceased tensferrad tc tne Royal Crnopaadic Hospital Lafore 08.00 hours On 5"h February 2015 was carcellad (0n the wrcng basig Inat no spare bed was avalatle) ard tne cancellaticn cf tne transler %35 not commun cated back to the consutant Additiorally an inztruction by the consuliant to 3 juniar doclar directing his Regigtrar to reviaw Mr Catanach was only parly aclad upon; This led tcacclay in the senicr rvicw of Mr Catanach which, "hen ittock place 9 nours after admissicn, recognised a deterioraticn in his condition It is a matter for the Trusl lo refecton how bes: lo onsure thet Consultants' instruct zns are fully actec Upon end wherc, for whatever reascn; that provzs impossible; tne situation Is communicated bzck to the Consultant concernad (3) Alrnost Immed ately atter his admissicn into the Royal Orthoraedic Hcspital with a fractured dislocation cf Inls neck Mr Catanach Iell cU: of this hzsFilal bed This was Frobably due to nim atemping to g2t UP to uz0 the tjilet Mr Calanacn'3 Iall tock plazu Even though twj members cfthe nursing slaff had expressly told Mr Catarach not lo move ard provided him with 2 EuZZEI Ihrcugh which to seak nursing assistance required Mr Newton-Ede; having reflected uoon tne matter teil Inat Simiiar Patients In fujure May be belter protected by @ Iransfer intc the HDU ratherthan & standard ward, The Trustmay wish tc reflect Dn whether this is a realistic alternative, If Implemerted this charje wIll need to he audited to se8 wnethar therg are suffciert tesoutces availabla within HDU Ifrcl, an altemative czursa olaction ccnsicered alinquest was that far Ihe small number Df pallerts odmitted with ar unstaole neck frazture i may be appropriale Immediately to atrarge ore to cne rursing caro pending operative lixation of tha iraclure (4} Tractcn equipment Nr Catanach had a halo crown filled In an atemptto Teduce Iha Iracture ne had sullered: At tne time Ihls wa? undertaken Mr Newlon-Ede did nct have avaiablato him the required Balkan beam traction equipment and a Swan reck davice was USCd instaad This was plairly inferiar and Indeed & pulley wheel was found to have jammed Ine following marring rendering the traction Ineffective and causing Ine fracture toslipback It taak 48 nours Fcr tha CXaCl tractcn Equinmeni to D0 found It was Lkely thatthe equipmient was available Ihe whole time but that eitner staff did nztknow whare i wZs KEpT Dr Ihose seni to find itd d not krow for whatthey were Icoking Itis a mallor for the Trus: to rellec: on hcw tc remedy Ihis sliuation, It %culd secm inat training cf relevant staff woul) be 3 &ensible first step Ine celay Uhe

(5} heard evidence atthe irquest that tnere was no safe and effective wa} of 3 patient traction to naveaCT scan vathou: tho traciian weights being released While as told Lha: only a small numbor cf patlerts wll requlre both Traction and 3 CT scan it maybe tnat the Tust corsiders Inai this [5 somelning tnat should DC considerod furher