A CORONER’S report into the death of a 70-year-old man at Torbay Hospital has highlighted ‘a gap in cover which puts patients at risk’.

In a Prevention of Future Deaths Report which has just been published, Devon, Plymouth and Torbay coroner Stephen Covell makes a call for action to the chief executives of the NHS Devon and NHS Cornwall and Isles of Scilly Integrated Care Boards.

The man died on December 29 2023 as a result of complications from a broken neck suffered in a fall at his allotment the previous day. There were no witnesses to the fall.

An inquest heard the man also had a background of ankolosing spondylitis, which is a long-term form of arthritis that mainly affects the spine and pelvic joints.

The coroner’s report says the management of the man’s treatment at Torbay Hospital was compromised when the report of a CT scan failed to identify a ‘high suspicion’ of blood pooling between the lungs and the chest wall.

It goes on to say his care was ‘not being led and directed by a clinician with appropriate experience for the complexity of the case’.

And, it adds: “Care should have been transferred to the nearest major trauma centre at Derriford Hospital in Plymouth.”

The inquest, which reached a conclusion of accidental death, heard that clinicians in Torbay Hospital’s Emergency Department identified an unstable fracture and a suspected haemothorax, which is the pooling of blood.

A plan was made to transfer the patient to Derriford, but before that could happen a registrar-grade radiologist discounted any haemothorax. At the time there was no consultant radiologist on call to review the report.

The coroner’s report goes on; “A consultant radiologist has recently reviewed the scan and indicated that it should have been reported as identifying a high suspicion of haemothorax.

“It is likely that the report wrongly discounting the haemothorax influenced the treatment plan for the deceased and contributed to his not being transferred appropriately to the major trauma centre for treatment.”

The man died at Torbay Hospital the following day. The cause of his death was listed as a lung infection, the fall and neck fracture, and arthritis.

The report adds: “In the light of the injuries which the deceased suffered on a background of a complex medical history involving his spine and chest, he should have been transferred to the major trauma centre at Plymouth as soon as the extent of his injuries and his previous medical history became known.”

Mr Covell’s report goes on to say that the level of complexity of the man’s condition required the expertise of a consultant radiologist.

“I was informed that there was (and is still) no out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay,” he adds.

“I am concerned that there will be from time to time a need for scans and x-rays to be considered and interpreted at consultant radiologist level to facilitate urgent treatment and there is at present a gap in such cover which puts patients at risk.”

In their response the two integrated care boards express condolences and say consultant radiologist cover is available 24 hours a day. In Torbay and South Devon NHS Foundation Trust consultant radiologists are working on site from 8am to 10pm and are on call overnight.

They do not routinely stay within radiology departments overnight, they say, but can be contacted ‘at all times’ for advice, review and support when needed.

Registrars and doctors can seek consultant radiologist input where cases are complex, findings are uncertain or urgent specialist advice is required.

The response goes on: “Notwithstanding this, we recognise the concern raised by the circumstances of this case. Having reviewed the current arrangements, the boards have not identified an absence of consultant radiologist cover across Devon hospitals.

However, we will continue to work with provider organisations to ensure that existing arrangements remain safe, effective and appropriately governed.”