UK Inquiry Tracker

Richard Ridout

PFD Report All Responded Ref: 2019-0331

Date of Report 2 October 2019

Coroner Robert Simpson

Coroner Area West Sussex

Response Deadline ✓ from report 29 November 2019

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 29 Nov 2019

Coroner's Concerns (AI summary)

A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.

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(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out.

(2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC.

(3) There was evidence available to the medical staff involved in his treatment that Richard had consumed diazepam and buprenorphine prior to his arrival at hospital. Despite this information being available, the distracting injury to his shoulder and a complaint of neck pain no imaging of his c-spine was carried out.

(4) Whilst the undiagnosed conditions did not contribute to Richard Ridouts death I am concerned that the failure to escalate the assessment and treatment of a person involved in such a road traffic collision could lead to deaths in the future.

Responses

University Hospitals Sussex NHS Foundation Trust NHS / Health Body

28 Nov 2019

Action Planned
The Trust is developing a protocol for the management of trauma patients with differing accounts of the incident and a protocol for patients who have sustained a fractured scapula, to be completed within 3 months. (AI summary)

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Dear Mr. Simpson Re: Regulation 28 Report Richard Ridout Thank you for your letter dated 2 October 2019 under cover of which you enclosed a formal copy of the Regulation 28 report to Prevent Future Deaths_ The Trust welcomes the opportunity to revew the way that complex patients who sustain trauma are managed_ As part of this process, the PFD report has been shared with the A&E Consultants on both sides of the Trust and through teaching with the A&E junior Doctors. It will be shared with the Sussex Trauma network_ We can confirm that a protocol is being developed for the management of patients who have sustained trauma where there are differing accounts of the speed involved as well as emphasising that patients who are on term opiates or sedatives, whether prescribed or not; will often have reduced clinical signs so the level of clinical suspicion needs to be increased_ The need to give consideration to instigating a trauma call when there is an unclear account of the collision and, in particular; potential of a high speed impact; is included as part of the protocol: While there was no clear clinical indication for a full trauma CT scan on this occasion; we are currently developing protocol for the management of patients who have sustained fractured scapula: The protocol will advise that these patients should now have X-rays of their cervical spine and chest; with a lower threshold to perform a CT scan if clinically indicated: The work on protocols is taking place across the two hospital sites and will be complete within 3 months The Trust was saddened by Mr Ridout's death and would like to give our reassurance that the Trust has taken the opportunity to review our current practice to ensure we manage patients who have sustained trauma in the most safe and effective way: long

Sent To

Western Sussex Hospitals NHS Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 29 Nov 2019

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 the 22nd February 2019 an investigation was opened into the death of Richard Lester Ridout, aged 43. The investigation concluded at the end of the inquest on 26th September 2019. The conclusion of the inquest was that ‘Richard Lester Ridout died as a result of Influenza A and streptococcal pneumonia causing sepsis which lead to multiple organ failure.’

Circumstances of the Death

On the 20th January 2019 Richard Ridout was involved in a single vehicle road traffic collision. His vehicle left the road and rolled over. Richard Ridout extricated himself from the vehicle after paramedics arrived. He was complaining of a pain in his shoulder and did not report any additional pain upon c-spine palpation. He reported that he had consumed 40mg diazepam and 8mg Buprenorphine. He stated to the ambulance staff that he had been travelling at 30 mph. On arrival at St Richard’s Hospital he was diagnosed with a fractured scapula. He complained of both neck and shoulder pain. A chest and pelvic x-ray were ordered but Richard declined the latter. He declined a full trauma examination. No additional pain was reported on c-spine palpation. He informed the junior doctor that he had been travelling at 50-60mph. His c-spine was not imaged, a trauma series CT was not requested and a trauma call was not put out. On the 29th January 2019 Richard was readmitted to hospital and transferred to St Guy’s & Thomas’ due to respiratory failure. Fractures of his C7 and C5 vertebrae were discovered along with pulmonary contusions. He was in septic shock and contracted the infections noted above. I found that the fractures had been caused by the road traffic collision on the 20th January 2019.