Jordanne Roberts
PFD Report
All Responded
Ref: 2025-0326
All 1 response received
· Deadline: 21 Aug 2025
Coroner's Concerns (AI summary)
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.
View full coroner's concerns
1) Jordanne’s death arose because a locum doctor, said to be the most senior doctor on duty in the Emergency Department on 10.8.24, 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;
2) In her evidence at inquest, ( Head of Patient Safety at the Trust ) confirmed: (a) that all of the Trust’s own employed doctors receive training so that they ensure that both parts of any CT scan report are read; (b) that all new locum doctors working for the Trust are provided with an induction pack, which highlights the requirement to read both parts of any CT scan report. However, was unable to confirm that steps have been taken to ensure that all locum doctors already working at the Trust have received the equivalent training. She indicated that they have been invited to attend education sessions in which this topic has been covered, but that no record is kept of whether those doctors did in fact attend.
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 that patients’ lives may be put at risk.
2) In her evidence at inquest, ( Head of Patient Safety at the Trust ) confirmed: (a) that all of the Trust’s own employed doctors receive training so that they ensure that both parts of any CT scan report are read; (b) that all new locum doctors working for the Trust are provided with an induction pack, which highlights the requirement to read both parts of any CT scan report. However, was unable to confirm that steps have been taken to ensure that all locum doctors already working at the Trust have received the equivalent training. She indicated that they have been invited to attend education sessions in which this topic has been covered, but that no record is kept of whether those doctors did in fact attend.
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 that patients’ lives may be put at risk.
Responses
Action Taken
Worcestershire Acute Hospitals NHS Trust discussed the learning from the investigation via teaching and board rounds, sent an email containing this learning to all doctors including locums, and circulated a lesson of the week reminding staff of the need to read both parts of a CT scan report. (AI summary)
Worcestershire Acute Hospitals NHS Trust discussed the learning from the investigation via teaching and board rounds, sent an email containing this learning to all doctors including locums, and circulated a lesson of the week reminding staff of the need to read both parts of a CT scan report. (AI summary)
View full response
Dear Mr Reid
Re Regulation 28 Report to Prevent Future Deaths
Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 1st July 2025, following the Inquest on the death of Jordanne Rose Roberts.
In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT).
“That unless and until the Trust is able to ensure that all locum doctors working at it’s 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 that patients lives may be put at risk.”
In response to your specific concerns listed above please find below the actions the trust have taken:
- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)
In addition to this:
- The Trauma pathway is undergoing a huge change but is still in discussion phases that have not yet been made live.
- Adding an additional pop-up reminder at the point of raising the CT request will be added into the process under construction.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email:
Chair:
Acting Chief Executive:
The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Please let me know if you require any further information.
Re Regulation 28 Report to Prevent Future Deaths
Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 1st July 2025, following the Inquest on the death of Jordanne Rose Roberts.
In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT).
“That unless and until the Trust is able to ensure that all locum doctors working at it’s 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 that patients lives may be put at risk.”
In response to your specific concerns listed above please find below the actions the trust have taken:
- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)
In addition to this:
- The Trauma pathway is undergoing a huge change but is still in discussion phases that have not yet been made live.
- Adding an additional pop-up reminder at the point of raising the CT request will be added into the process under construction.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email:
Chair:
Acting Chief Executive:
The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Please let me know if you require any further information.
Sent To
- Worcestershire Acute Hospital NHS Trust
Response Status
Linked responses
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56-Day Deadline
21 Aug 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 3 September 2024 I commenced an investigation and opened an inquest into the death of Jordanne Rose ROBERTS. The investigation concluded at the end of the inquest on 25 June 2025.
The conclusion of the inquest was that Jordanne “died from an undiagnosed pulmonary embolism. Her death was contributed to by neglect”.
The conclusion of the inquest was that Jordanne “died from an undiagnosed pulmonary embolism. Her death was contributed to by neglect”.
Circumstances of the Death
In answer to the questions “when, where and how did Jordanne come by her death?”, I recorded as follows:
“On 10.8.24 Jordanne Roberts was assessed in the Emergency Department of the Alexandra Hospital, Redditch after falling down stairs at her home in Kidderminster. The locum doctor who assessed her discharged her home without waiting to read a full CT scan report, which identified that she had a pulmonary embolism. On the morning of 12.8.24 Jordanne collapsed suddenly at home, and died a short time later. A post mortem examination confirmed the cause of death to be a pulmonary embolism. Her death would probably have been prevented if the pulmonary embolism had been identified and treated in hospital.”
“On 10.8.24 Jordanne Roberts was assessed in the Emergency Department of the Alexandra Hospital, Redditch after falling down stairs at her home in Kidderminster. The locum doctor who assessed her discharged her home without waiting to read a full CT scan report, which identified that she had a pulmonary embolism. On the morning of 12.8.24 Jordanne collapsed suddenly at home, and died a short time later. A post mortem examination confirmed the cause of death to be a pulmonary embolism. Her death would probably have been prevented if the pulmonary embolism had been identified and treated in hospital.”
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.