John Cleave

I am Stephen Covell, Assistant Coroner for the coroner area of Devon, Plymouth and Torbay.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be  checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN There appears to be no 24 hour Consultant Radiologist cover across Devon’s hospitals to review and report on complex x-rays or scans requiring consultant level expertise.

a Aspiration Pneumonia b Fall and Cervical Spine Fracture 2 Ankolosing Spondylitis In answer to the how, when and where questions I recorded; John Thomas Cleave died at 1800 on 29 December 2023 at Torbay Hospital as a result of  complications from a cervical spine fracture sustained in an unwitnessed fall whilst the  Deceased was at his allotment at around 1700 the previous day against a background of  ankolosing spondylitis. The management of the Deceased’s treatment at hospital was  compromised by the radiological report of a CT-Scan failing to identify a high suspicion of a  haemothorax and the Deceased’s care not being led and directed by a clinician with  appropriate experience for the complexity of the case. Care should have been transferred to the nearest major trauma centre at Derriford Hospital in Plymouth. Conclusion Accidental Death