Recurring concern

Unreliable out-of-hours interventional radiology support

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First reported 22 Apr 2015•Latest report 28 May 2024

Definition

What this concern includes

Includes failures in the dedicated out-of-hours interventional radiology support arrangement, including availability of appropriately skilled radiologists, on-call rotas, cross-hospital coverage, contact and escalation routes, and timely access to procedures such as percutaneous cholecystostomy where the deficiency is specifically part of that support system.

Not included

  • Excludes ordinary-hours radiology access and generic radiology reporting or interpretation failures that are not specifically concerned with out-of-hours interventional radiology support.
  • Excludes shortages of unrelated clinical specialties, procedures or diagnostic services unless the assertion explicitly concerns interventional radiology support.
  • Excludes generic staffing, communication or transfer deficiencies where no out-of-hours interventional radiology availability or support failure is identified.
  • Excludes failures occurring after appropriate out-of-hours interventional radiology support has been obtained, including the quality of the procedure itself.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2
Department of Health and Social Care1
Dorset County Hospital NHS Foundation Trust1
East Kent Hospitals University NHS Foundation Trust1
NHS West Yorkshire Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
West Yorkshire and Harrogate Integrated Stroke Delivery Network1
Wirral University Teaching Hospital NHS Foundation Trust1
Worcestershire Acute Hospitals NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Dorset

    AI-generated summary

    Christine Rita Booker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christine Rita Booker underwent elective right total hip replacement surgery on 23 February 2023 and became critically unwell after extensive bleeding, subsequently dying at Royal Bournemouth Hospital on 24 February 2023. The report raises concern that the lack of out-of-hours interventional radiology at Dorset County Hospital required urgent patients to be transferred, potentially causing significant delays to life-saving treatment and increasing the risk of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of out-of-hours interventional radiology at Dorset County Hospital

    Wider context from the report

    “1. During the inquest evidence was heard that: i. There is no out of hours interventional radiology at Dorset County Hospital and that patients requiring this potentially urgent and life-saving intervention that live in the West of the County require transfer to the Royal Bournemouth Hospital for treatment. 2. I have concerns with regard to the following: i. Because of the lack of out of hours interventional radiology at Dorset County Hospital, patients in the West of the County requiring such an intervention must be transferred to the Royal Bournemouth Hospital. This exposes these patients to a potentially considerable and significant delay in the provision of urgent and life-saving treatment, which, in turn, exposes them to an increased risk of death. ”

    Source location

    Christine Rita Booker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS England, as commissioner, is responsible for addressing the provision of 24/7 emergency specialist interventional radiology.

    Verbatim wording from the response

    “We have reviewed the findings of the inquest, and the recommendations as stated in the Preventing Future Deaths report and can confirm that the Trust does not provide a 24/7 emergency service for specialist interventional radiology for embolization. This is a specialised service commissioned by NHS England, provided by University Hospitals Dorset from their site at the Royal Bournemouth Hospital for both Dorset County Hospital and Salisbury Hospital. 24/7 specialised interventional radiology services are not available in every local hospital because they are delivered by specialist teams who have the necessary skills, experience and volume of work to maintain safe standards of care across wider geographical areas.”

    Source location

    Response from Dorset County Hospital
    Page 1 · response
    Published 31 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The established hub-and-spoke vascular model and private-provider transfer pathways are considered sufficient for Dorset patients requiring vascular intervention.

    Verbatim wording from the response

    “Dorset Integrated Care Board advise that there is a well-practiced hub and spoke model with the Royal Bournemouth Hospital for vascular services, as well as clear pathways for private provider transfer. They advise that a full interventional radiology service at Dorset County Hospital would likely be unsustainable.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A full interventional radiology service at Dorset County Hospital is considered likely unsustainable, limiting expansion of local provision.

    Verbatim wording from the response

    “Dorset Integrated Care Board advise that there is a well-practiced hub and spoke model with the Royal Bournemouth Hospital for vascular services, as well as clear pathways for private provider transfer. They advise that a full interventional radiology service at Dorset County Hospital would likely be unsustainable.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 May 2024

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Jasbir Pahal · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jasbir Pahal suffered an acute left middle cerebral artery stroke on 13 November 2022 and was transferred between hospitals while arrangements for thrombectomy were being considered. Imaging later showed extensive infarction, active treatment was withdrawn on 27 November, and she died on 30 November 2022. The principal concern was that thrombectomy access for patients at Calderdale Royal Hospital was available only during limited weekday hours, leaving patients without reliable access to potentially life-saving treatment outside those hours and subjecting access to local arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy

    Wider context from the report

    “(6) That this level of service is inadequate is illustrated by the historical practice of thrombectomies being performed at LGI outside of the stated hours on an occasional ad hoc basis, dependent (among other factors) upon the availability and willingness of an interventional neuroradiologist to attend on a voluntary basis when not on call, to perform a potentially life-saving procedure. Among other reasons, it being considered inappropriate that clinicians should be exposed to the moral dilemma of agreeing or declining to perform such a life-saving procedure outside of their working or on-call hours, LTHT has as from June 2023 stopped accepting such ad hoc referrals. ”

    Source location

    Jasbir Pahal · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Manchester West

    AI-generated summary

    Stanley Oliver · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stanley Oliver, aged 85, died at Salford Royal Hospital after being admitted with abdominal pain and a perforated gall bladder. A drainage procedure was not performed over the weekend because there was no out-of-hours rota for GI Radiologists, and the report raised concerns about the availability, communication arrangements and training needed for urgent procedures of this kind.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of out-of-hours availability of GI Radiologists to perform percutaneous cholecystostomy

    Wider context from the report

    “1. During the Inquest evidence was heard that: i. There was no on call rota for a GI Radiologist to perform a percutaneous cholecystostomy out of hours and particularly over a weekend. The Hospital Trust indicated that a risk had been identified in relation to the unavailability of GI Radiologists out of hours and the Hospital that managed the risk by allowing the GI Radiologist to be contacted out of hours but the Trust accepted that there was no provision for the Radiologist to be available out of hours. ii. The Consultant Surgeon gave evidence at the Inquest that availability of a GI Radiologist to perform a percutaneous cholecystostomy was critical to the management of a patient and he raised concerns that there would be a risk to life if a percutaneous cholecystostomy could not be performed out of hours, either overnight or over a weekend. iii. I accepted evidence at the Inquest that the Salford Royal NHS Foundation Trust were considering actions to make GI Radiologist available out of hours and to establish a system for any Radiologist to contact a GI Radiologist our of hours for procedures to be conducted out of hours. However there was no confirmation that an out of hours on call rota was being considered for GI Radiologists either within the Salford Royal NHS Foundation Trust or for a rota relate to a wider area covering several other hospitals on the basis that an available Radiologist could travel to different hospitals to carry out a necessary procedure out of hours. iv. Evidence was given at the Inquest that the unavailability of GI Radiologists was not limited to Salford but was a national problem in that there were very few out of hours on call rotas for GI Radiologists in hospitals in the United Kingdom. It was accepted that a perforated gall bladder was a recognised condition, which occurred on a regular basis as an emergency presentation to hospital. In some cases surgical intervention would not be appropriate and an alternative treatment plan would involve the insertion of a percutaneous cholecystostomy drain or a drain to be inserted outside the gall bladder, both of which would require insertion by a GI Radiologist. v. The evidence raised concerns that there is a risk of future deaths will occur unless action is taken to review the above issues. ”

    Source location

    Stanley Oliver · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the Standard Operating Procedure to reflect weekend non-vascular interventional radiology arrangements.

    Verbatim wording from the response

    “The short term plan is to continue to use the SRFT ad hoc service with additional support from Central Manchester NHS Foundation Trust (CMFT). CMFT plan to have a weekend non-vascular intervention service from October 2015 and have agreed that they will support our service and perform cases that we are not able to safely perform at SRFT at weekends. A Standard Operating Procedure (SOP) has been updated to reflect this change (Appendix 2) and further details can be found in the action plan below.”

    Source location

    S-Oliver-Response
    Page 3 · response
    Published 16 July 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a 1-in-6 non-vascular interventional radiology rota at SRFT to provide seven-day Consultant-level cover by April 2016.

    Verbatim wording from the response

    “The medium term plan is to develop a 1 in 6 non-vascular intervention rota at SRFT to ensure that there is 7 day cover at Consultant level by April 2016. This will involve a number of detailed actions which are described further within the action plan below. Whilst this has”

    Source location

    S-Oliver-Response
    Page 3 · response
    Published 16 July 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with Greater Manchester acute provider trusts to share interventional radiology expertise and improve equitable seven-day access.

    Verbatim wording from the response

    “The issues highlighted by this case reflect a national shortage of Consultant Interventional Radiologists and are not particular to SRFT with no acute provider Trust in Greater Manchester being able to provide a comprehensive out of hours IR service. We recognise our role in making sure that access to IR is equitable across 7 days not just at SRFT but more widely across GM and we will be working with the other acute provider Trusts across Greater Manchester to ensure expertise is shared.”

    Source location

    S-Oliver-Response
    Page 4 · response
    Published 16 July 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Each local NHS Trust is responsible for providing out-of-hours rotas, availability procedures and staff training in those protocols.

    Verbatim wording from the response

    “I note that your letter has been sent to the SRH Trust and I would expect the Trust to fully address these concerns.”

    Source location

    2015-0281-Response-by-Department-of-Health
    Page 1 · response
    Published 16 July 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A comprehensive out-of-hours interventional radiology service cannot currently be delivered because of a national shortage of skilled consultant radiologists.

    Verbatim wording from the response

    “As with many NHS acute provider Trusts across the country, the IR service at SRFT is currently unable to deliver a comprehensive out of hours (OOH) service.”

    Source location

    S-Oliver-Response
    Page 2 · response
    Published 16 July 2015

    Open published response

  4. West Yorkshire (Western)

    AI-generated summary

    Marie Gretta Harding · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marie Gretta Harding, who had chronic obstructive pulmonary disease, was admitted with breathlessness and a left-sided pneumothorax requiring chest drains. A chest drain inserted on 12 October 2014 more likely than not penetrated her left lung, after which she deteriorated and died on 14 October 2014. The inquest identified a lack of Trust guidelines and up-to-date training for chest drain insertion, and unawareness of the availability of an on-call interventional radiologist.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of awareness of on-call weekend availability of interventional radiologists

    Wider context from the report

    “During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains, lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist. Although I acknowledge that the Trust has now fully instigated remedial changes in this regard; ”

    Source location

    Marie Gretta Harding · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Worcestershire

    AI-generated summary

    Noel Owen JONES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Noel Owen JONES underwent surgery on 2 October 2014 and was later admitted to Hereford County Hospital severely unwell with an internal haemorrhage. He was ultimately transferred by ambulance to Worcestershire Royal Hospital, where he died shortly after arrival, following an apparent four-hour delay in acceptance. Concerns included evidence that earlier acceptance might have enabled survival and that Worcestershire Royal Hospital had no out-of-hours vascular surgery or interventional radiology service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of an out-of-hours interventional radiology service

    Wider context from the report

    “(2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology ”

    Source location

    Noel Owen JONES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review out-of-hours and on-call arrangements for vascular surgery or interventional radiology transfers involving critically ill patients.

    Verbatim wording from the response

    “I am writing with reference to your letter dated 22 April 2015 in which you raised two concerns regarding Trust procedures following evidence which you heard at the inquest into the death of Mr Jones. As a result of your letter I confirm that I have reviewed the Trust’s processes in respect of the following action:”

    Source location

    2015-0155-Response-by-Worcestershire-NHS-Trust
    Page 1 · response
    Published 22 April 2015

    Open published response
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Data last updated 7 September 2026