Craig Green, 39, a catering assistant at Queen Elizabeth Hospital in Birmingham, died on a Selly Oak ward in July last year, two days after suffering a devastating brain injury caused by a ruptured aneurysm. His death has left his partner and their three young sons devastated.
Months before his death, a scan carried out during an ENT appointment had “incidentally” revealed the presence of a brain aneurysm — a serious and potentially life-threatening condition. However, Craig was never informed of the finding, nor was his GP, due to what the inquest heard were failures in communication and documentation.
University Hospitals Birmingham NHS Foundation Trust (UHB), which runs Queen Elizabeth Hospital, described Craig’s death as a “tragic incident” involving a “much-loved colleague” and said changes had been made to prevent a similar case happening again.
Craig had attended the hospital’s Ear, Nose and Throat clinic in April after experiencing sudden hearing loss. Although he had no symptoms linked to an aneurysm, scan results later that month revealed the condition.
The inquest heard that a consultant emailed the findings to the neurovascular multidisciplinary team, but because the referral was not submitted using the required proforma, it was never formally processed. As a result, neither Craig nor his GP were told about the aneurysm.
The coroner was told there were several missed opportunities and failings by the trust, including:
- Failure to make an appropriate referral to the neurovascular MDT
- Poor documentation of communication
- Failure to clearly explain which investigations had been carried out and which still required review
- No clear feedback that the referral would not proceed without the correct proforma
Despite these failings, the coroner concluded they did not directly contribute to Craig’s death, as any treatment would likely not have begun until September.
Craig’s partner, Lesley Claridge, told the inquest that had they known about the aneurysm, Craig could have made lifestyle changes, reduced his risk of rupture and avoided feeling pressured to return to work.
“He was loyal to his job and proud to work there,” she said. “That is why it is so devastating that, in the very same hospital where he worked, there were tragic failings and missed opportunities in his care.
“I feel deeply hurt, angry and let down that more was not done for him when it was needed. Knowing that things could have been different is something I will carry forever.”
Ms Claridge said she has been left raising their three sons alone while coping with grief, financial strain and emotional trauma.
“The reality is harsh — I am learning how to survive without the person who supported me in every way,” she said.
An internal investigation was carried out by consultant cardiothoracic surgeon Stephen Rooney, who identified recurring issues around poor communication and inadequate documentation. A four-point action plan was issued to the trust, including clearer handover processes, mandatory communication of incidental findings to patients and GPs, and explicit referral requirements for neurovascular teams.
All four actions have now been implemented, the court was told.
Mr Rooney said: “It is a recurring theme in medicine that many complaints stem from poor communication and inadequate documentation. It is something we constantly reiterate clear communication saves lives.”
In a statement issued after the inquest, UHB said: “We offer our sincerest condolences to Craig’s family and acknowledge the devastating impact caused by this tragic incident. Craig was a much-loved colleague who is deeply missed.
“Following a full investigation into his care, we have strengthened communication processes and referral pathways to help prevent this from happening again.”
