Recipient

Medica Reporting Limited

First report 12 May 2021•Latest report 12 May 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 6

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Medica Reporting Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

12 May2021
Manchester South
Concerns raised1
1. Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.
  Stated completed
2. Action
  Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.
  Stated in progress
3. Action
  Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.
  Stated completed
1. Action
  Share learning from this case with reporting radiologists.
  Stated planned
2. Action
  Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.
  Stated planned
3. Action
  Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.
  Stated completed
Respondent positions 3
1. Position
  The reporter normally uses MPR tools, so the concern that their use was not assured is disputed.
  Disputes the concern
1. Position
  MPR tool use cannot be monitored or measured in a simple or meaningful way.
  Unable to act
2. Position
  Existing MPR training, guidance, auditing, refresher training and shared learning address MPR use in CT reporting.
  Existing arrangements considered sufficient
AI-generated summary

MARY ANNE MELLOR · 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

Mary Anne Mellor died at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent. The leak was not identified on CT scans in 2019 and 2020 because 3D reconstruction was not used. Concern remained that other patients with aortic stents could be at risk of leaks not being identified, potentially depriving them of elective surgical management before life-threatening complications occurred.

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. The report was sent to Medica Reporting Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Wider context from the report
“(1) Following a thorough investigation, I HCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported. LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of the date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future. (2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur. ”
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
Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.

Verbatim wording from the response
“8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.

Verbatim wording from the response
“8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.

Verbatim wording from the response
“2. Medica routinely trains reporters in the use of the Radiology image viewing system (Medica Insignia PACS system) including the use of Multiplanar Reformatting (MPR) for the interpretation and reporting of all cross-sectional imaging (CT and some MRI). MPR is a term used to describe the type of 3D reconstruction that would be used in the case of the deceased.”

Source location
2021-0153-Response-from-Medica-Redacted
Page 2 · response
Published 18 May 2021
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
Share learning from this case with reporting radiologists.

Verbatim wording from the response
“8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.

Verbatim wording from the response
“11. It is not possible to monitor/measure the use of MPR tools in a simple or meaningful way but experienced analysis of reporting discrepancies can lead the reviewer to highlight this to reporting radiologists when the reviewer considers that this may be a contributory factor. Medica will as a result of this notice, remind case reviewers of the importance of the use of MPRs.”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.

Verbatim wording from the response
“5. In September 2020 Medica prepared an in-house training video which includes a section on MPR (3D) technique. This was notified to all reporting radiologists and placed in the online learning folder There is a training video and Radiology Reporting Process Guide for post training reference available to reporters at all times (Attachments 1.3 Screenshots from training video and 1.4 Radiology Reporting Process Guide).”

Source location
2021-0153-Response-from-Medica-Redacted
Page 2 · response
Published 18 May 2021
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 reporter normally uses MPR tools, so the concern that their use was not assured is disputed.

Verbatim wording from the response
“The above items evidence the importance that Medica places upon MPR functionality in CT reporting. The reporter in this case uses MPR in their normal workflow. It is therefore possible that it was employed at the time of reporting this study, but the endoleak was not recognised by the reporter. This is termed an observational error and is a recognised error in radiology. Medica places great importance on informing reporters of errors made by others to maximise learning opportunities and reduce error in the future as much as possible. We will be sharing the learning from this case with our reporters.”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
MPR tool use cannot be monitored or measured in a simple or meaningful way.

Verbatim wording from the response
“11. It is not possible to monitor/measure the use of MPR tools in a simple or meaningful way but experienced analysis of reporting discrepancies can lead the reviewer to highlight this to reporting radiologists when the reviewer considers that this may be a contributory factor. Medica will as a result of this notice, remind case reviewers of the importance of the use of MPRs.”

Source location
2021-0153-Response-from-Medica-Redacted
Page 3 · response
Published 18 May 2021
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
Existing MPR training, guidance, auditing, refresher training and shared learning address MPR use in CT reporting.

Verbatim wording from the response
“2. Medica routinely trains reporters in the use of the Radiology image viewing system (Medica Insignia PACS system) including the use of Multiplanar Reformatting (MPR) for the interpretation and reporting of all cross-sectional imaging (CT and some MRI). MPR is a term used to describe the type of 3D reconstruction that would be used in the case of the deceased.”

Source location
2021-0153-Response-from-Medica-Redacted
Page 2 · response
Published 18 May 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Actions described in response 6

Respondent positions 3