A much-loved hospital catering assistant died following a series of catastrophic failures and missed opportunities at the very NHS trust where he worked, an inquest has concluded.
A Devoted Father Let Down by the System
Craig Green, a 39-year-old father-of-three, died on a ward at the Queen Elizabeth Hospital in Selly Oak, Birmingham, in July last year. His death came just two days after he suffered a devastating ruptured brain aneurysm.
Tragically, the aneurysm had been discovered months earlier. A scan in April, prompted by concerns over sudden hearing loss, had incidentally uncovered the high-risk condition. However, due to what an investigation later called "poor communication and documentation", neither Craig nor his GP were ever informed of the life-threatening finding.
His devastated partner, Lesley Claridge, is now a single mother raising their three boys alone. She told the coroner that had they known, Craig could have made plans and lifestyle changes to reduce the risk of a rupture.
How the Communication Broke Down
The inquest heard that a consultant had shared the scan results showing the aneurysm with the neurovascular multi-disciplinary team via email. However, because the information was not submitted in the required 'proforma' format, the referral was never completed. This critical administrative failure meant the vital information never reached the patient.
Stephen Rooney, a consultant cardiothoracic surgeon who led an internal investigation, stated: "It is a recurrent theme in medicine, in particular in complaints with patients, that many of them are about poor communication and inadequate documentation; it is a recurring theme."
The University Hospitals Birmingham NHS Foundation Trust, which runs the hospital, acknowledged the tragedy. In a statement, they said: "We offer our sincerest condolences to Craig's family... Craig was a much-loved colleague, who is deeply missed."
Action Plan Implemented After Investigation
While the coroner was told these specific failings did not directly cause Craig's death—as treatment would likely not have started until September—the trust has been forced to act. Mr Rooney's investigation produced a four-point action plan to prevent a repeat of the tragedy.
The court heard that all four recommended actions have now been implemented by the trust. These focus on strengthening communication processes and referral pathways between departments.
Lesley Claridge expressed her profound grief and anger, stating: "He was loyal to his job and proud to work there. 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."
She added: "The reality is harsh — I am having to learn how to survive without the person who supported me in every way." The family's loss underscores the human cost of systemic failures within the NHS.
