5 Dec 2025 Man Yin ‘Anita’ Ng · Prevention of Future Deaths report Coventry
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Concerns raised 3 Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages View source Variation in the availability of neurointerventional procedures View source Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms View source
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AI-generated summary
Man Yin ‘Anita’ Ng · 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
Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Variation in the availability of neurointerventional procedures
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” Open source report
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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 partner organisations to advocate for sustainable workforce planning, clearer clinical governance, and equitable access to specialist interventional services.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and update professional guidance and standards supporting timely care and clarifying roles and responsibilities in complex multidisciplinary pathways.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS providers, commissioners and national bodies are responsible for organising, resourcing and operationally delivering emergency and specialist services.
Verbatim wording from the response “The Royal College of Radiologists (RCR) is a charity which works with our members and Fellows to improve medical care across the specialties of Clinical Radiology and Clinical Oncology. The RCR does not commission, fund, manage, or directly deliver clinical services. Responsibility for the organisation, resourcing, and operational delivery of emergency and specialist services lies with NHS providers, commissioners, and national bodies. However, the RCR has an important role in setting professional standards, providing guidance, supporting workforce development, and advocating for system-level change where patient safety and service sustainability are at risk.” Source location Response from The Royal College of Radiologists
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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 RCR cannot mandate service reconfiguration or staffing levels, limiting its ability to implement those changes directly.
Verbatim wording from the response “While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways.” Source location Response from The Royal College of Radiologists
Open published response
Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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× 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
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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 Support initiatives aimed at addressing current and future demand for radiology services.
Verbatim wording from the response “The RCR does not directly run radiology training which is a function of the NHS in all four nations. We are actively engaged in efforts to encourage expansion of radiology training capacity and continue to contribute to national workforce planning conversations and support initiatives aimed at addressing current and future demand. Our vision is one of collective improvement so that all patients, irrespective of location, receive timely and accurate diagnostic care.” Source location Response from Royal College of Radiologists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to national workforce planning discussions addressing radiology staffing shortages.
Verbatim wording from the response “The RCR has long recognised the critical shortage of radiologists in the UK. This issue has been a consistent theme across several other Prevention of Future Deaths reports received in recent years and has been central to our advocacy efforts. As outlined in our 2023 Clinical Radiology Workforce Census Report, the specialty is facing a 30% shortfall in consultant radiologists, projected to rise to 40% by 2028 if no action is taken. The next annual workforce census report will be published in June 2025 but to date there has not been investment anywhere close to what would be required to close that gap. The demand for imaging” Source location Response from Royal College of Radiologists
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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 Encourage expansion of radiology training capacity to address current and future workforce demand.
Verbatim wording from the response “The RCR has long recognised the critical shortage of radiologists in the UK. This issue has been a consistent theme across several other Prevention of Future Deaths reports received in recent years and has been central to our advocacy efforts. As outlined in our 2023 Clinical Radiology Workforce Census Report, the specialty is facing a 30% shortfall in consultant radiologists, projected to rise to 40% by 2028 if no action is taken. The next annual workforce census report will be published in June 2025 but to date there has not been investment anywhere close to what would be required to close that gap. The demand for imaging” Source location Response from Royal College of Radiologists
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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 NHS in all four nations is responsible for directly running radiology training, rather than the respondent.
Verbatim wording from the response “The RCR does not directly run radiology training which is a function of the NHS in all four nations. We are actively engaged in efforts to encourage expansion of radiology training capacity and continue to contribute to national workforce planning conversations and support initiatives aimed at addressing current and future demand. Our vision is one of collective improvement so that all patients, irrespective of location, receive timely and accurate diagnostic care.” Source location Response from Royal College of Radiologists
Open published response
14 Mar 2025 Dominic Martin PHILIP · Prevention of Future Deaths report Northamptonshire
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Concerns raised 3 Unexplained exposure to Lidocaine, including for people allergic to Lidocaine View source Lack of pre-injection identification of potential allergy to iodinated contrast agents View source Failure to maintain accountable removal and stock counts for Lidocaine View source
Responses linked to these concerns
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AI-generated summary
Dominic Martin PHILIP · 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
Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Unexplained exposure to Lidocaine, including for people allergic to Lidocaine
Wider context from the report “b) Mr Philip did disclose an allergy to Lidocaine. The toxicology report records that Lidocaine was detected in Mr Philip’s blood post-mortem. Despite the hospital conducting a comprehensive review of the care provided, it has not been possible to ascertain why Lidocaine was present in Mr Philip’s system . Aside from the contrast medium, the only medication that Mr Philip received at hospital was IV Tazocin, IV paracetamol, Oramorph and IV saline. The toxicologist has also ruled out any possibility of contamination of the blood sample during testing. The toxicologist adds “I note that Mr Philip described as healthy so I would not expect its use outside a hospital setting”. There was no other source identified at inquest . I am therefore concerned that Mr Philip has come into contact with Lidocaine without any explanation – could there be a contaminated supply of medication? Have there been any similar unexplained occurrences anywhere else in the country? This is of course of particular concern to those who, like Mr Philip, are allergic to Lidocaine .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-injection identification of potential allergy to iodinated contrast agents
Wider context from the report “a) It was stated in evidence that - an X-Ray is no longer preferred as it is not sensitive enough and a smaller obstruction might be missed; anaphylactic type reactions to iodinated contrast agents are rare accounting for 0.6% of cases with only 0.04% considered aggressive; and almost all contrast reactions that are life threatening occur within 20 minutes of intravenous injection. The current policy appears to be that a patient referred for a CT scan by the Emergency Department is to be accompanied by a doctor trained in advanced life support (ALS). In Mr Philip’s case, he was accompanied by a Core Trainee Year 2 who had ALS training. The policy for planned/outpatient interventions was not fully explored at inquest, but there was a suggestion that there might be some possibility testing for an allergic reaction to the contrast medium in advance of such an appointment? My concern is that if a patient has never before had contrast medium (as was the case with Mr Philip) they cannot possibly know if they have an allergy to it . Making arrangements for ALS after the event seems reactionary and I wondered if any other options might be available which would flag a potential allergy before the contrast is injected .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accountable removal and stock counts for Lidocaine
Wider context from the report “c) It has also been brought to my attention in a different case currently under investigation within my jurisdiction that as Lidocaine is a prescription only medication, it needs to be stored in a locked cupboard. However, Lidocaine is not a Controlled Drug which means that clinicians do not need a double signature to remove the medication from the stock and it is not subject to a count of the stock each time an ampoule is used . The Hospital has stated that “The use of Lidocaine will vary within each area dependant on the patients being seen within each department and treatments given. Stock levels are reviewed by pharmacy to ascertain stock required. Unless a large amount of stock was removed from a single clinical area there would be no alert to indicate that Lidocaine was being removed for reasons other than patient treatment ”.
” Open source report
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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 and publish guidance on administering iodinated contrast media and gadolinium through the established working party.
Verbatim wording from the response “There are several different manufacturers of iso-osmolar iodinated contrast medium (ICM) which is typically used when a CT scan is performed. For a number of years the UK radiology community has looked to the European Society of Urogenital Radiology and the Royal Australian and New Zealand College of Radiologists guidelines on the use of such ICM. The RCR has recently established a working party to develop ICM guidance that will provide recommendations on the administration of iodinated ICM and gadolinium. We anticipate this guidance will be published in early 2026.” Source location Response from The Royal College of Radiologists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine pre-exposure allergy testing for iodinated contrast medium is not considered necessary because reactions are rare and testing could delay urgent CT scans.
Verbatim wording from the response “Regarding drug allergies, it is an inherent characteristic of all medications that a patient may not be aware of an allergy until they are exposed to the drug. Given the very low incidence of allergic reactions, routine pre-exposure testing for all patients is not standard medical practice for most medications and ICM has a lower incidence of provoking an anaphylactoid reaction than many other medications which are similarly not assessed.” Source location Response from The Royal College of Radiologists
Open published response
2 Jan 2025 Gemma Suzanne Marshall · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 2 Lack of radiologist knowledge of how slipped gastric bands present View source Failure to recognise and report slipped gastric bands on imaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gemma Suzanne Marshall · 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
Gemma Suzanne Marshall underwent private gastric-band surgery in 2020, attended hospital with black vomiting and lower abdominal pain in March 2024, and died after the band slipped. The report raises concern that an outsourced radiologist failed to identify and report the slipped band on a CT scan, contributing to a failure to refer her to bariatric specialists. It also identifies wider concerns about radiologists’ familiarity with slipped bands and reliance on non-specialist or outsourced reporting during staff shortages.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of radiologist knowledge of how slipped gastric bands present
Wider context from the report “Evidence was given by the consultant surgeon who fitted the band, a senior bariatric surgeon at the treating hospital and a consultant radiologist at the treating hospital that the gastric band had slipped.
A CT scan was undertaken on 13.03.24 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company. This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.
This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.
Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present , something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialists which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialist because of staff shortage.
While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and report slipped gastric bands on imaging
Wider context from the report “Evidence was given by the consultant surgeon who fitted the band, a senior bariatric surgeon at the treating hospital and a consultant radiologist at the treating hospital that the gastric band had slipped.
A CT scan was undertaken on 13.03.24 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company. This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.
This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.
Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present, something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialists which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialist because of staff shortage.
While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.
” Open source report
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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 Ask the relevant editor to consider the case theme and signpost a suitable anonymised CT case for educational material.
Verbatim wording from the response “The RCR does publish educational material including anonymised cases and I have asked the” Source location Response from Royal College of Radiologists
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 Gastric-band slippage alone is not necessarily a surgical emergency, and recognising it may not have changed the outcome within the available timeframe.
Verbatim wording from the response “Gastric bands do sometimes move out of position. Slippage of a gastric band, however, is not in and of itself a surgical emergency unless accompanied by clinical features which indicate serious complications. These features are more usually obstructive symptoms rather than symptoms of gastric infarction. Given the circumstances of Ms Marshall’s death and because she was considered well enough to be self-caring and to be discharged home at the time of the CT, even if it had been recognised that the gastric band had slipped on the CT, surgical intervention may well not have taken place within the two-day time window between her initial presentation and subsequent death. Therefore, tragically, interpretation of the CT may not have been the only factor that required to change in order for Ms Marshall’s death to have been prevented.” Source location Response from Royal College of Radiologists
Open published response
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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 Emergency imaging cannot currently be reported by locally based subspecialists in every case because NHS staffing and IT provision make this impossible.
Verbatim wording from the response “Given the current state of staffing and IT provision in the NHS it is not currently possible for all emergency imaging to be reported by a local radiologist with sub-specialty expertise in the relevant area. This is as true of other sub-specialty areas of radiology (chest, neurology, musculoskeletal, gynaecology, paediatrics etc) as it is of abdominal imaging. The fact that the reporting radiologist had a specialist interest in a different area does make it inevitable they will be less expert at identifying very rare pathology in the abdomen. If the treating team have ongoing concerns, then in most imaging departments there is typically the opportunity to discuss the imaging with a local radiologist with greater relevant subspecialist knowledge during the working week.” Source location Response from Royal College of Radiologists
Open published response
8 Nov 2024 Lacey May Brookman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to reach a diagnosis in an ill patient View source Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain View source Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain View source Unavailability of bedside or departmental ultrasound scanning for abdominal pain View source Failure to consider appendicitis in patients with abdominal pain View source Failure to use bedside or departmental ultrasound scanning for abdominal pain View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lacey May Brookman · 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
Lacey May Brookman, aged 11, experienced more than a week of abdominal pain and related symptoms before retrocaecal appendicitis was diagnosed after perforation and abscess formation. She underwent surgery and developed severe complications, including coagulopathy, disseminated intravascular coagulation and multiorgan failure, and died on 4 June 2021. Concerns included difficulty recognising retrocaecal appendicitis, and the availability and use of abdominal ultrasound scanning and training for doctors considering the diagnosis.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to reach a diagnosis in an ill patient
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain
Wider context from the report “2. Despite the slant of available literature, it was evident retrocaecal appendicitis presentation is not a rare presentation of either acute appendicitis or generalised abdominal pain (both common presenting features in the young)
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain
Wider context from the report “4. The training of doctors in considering the diagnosis as a possible differential to generalised abdominal pain.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Unavailability of bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to consider appendicitis in patients with abdominal pain
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to use bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 Point-of-care ultrasound availability was unlikely to have been a critical factor because ultrasound and CT were available, yet imaging did not enable curative treatment.
Verbatim wording from the response “We note that ultrasound was available in the centre to which Lacey presented but that tragically even provision of ultrasound and CT on the day of the referral did not facilitate curative treatment.” Source location Response from Royal College of Radiologists
Open published response
11 Oct 2024 Kingsley Efosa Imafidon · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS View source Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS View source Lack of liaison between care teams about HbSS-relevant matters before liver biopsy View source Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kingsley Efosa Imafidon · 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
Kingsley Efosa Imafidon, who had homozygous sickle cell disease and suspected liver cirrhosis, underwent a liver biopsy on 29 November 2023. He was found unresponsive at home on 2 December 2023, and the post-mortem examination found extensive fresh haemorrhage into the peritoneal cavity following the biopsy. The concerns included lack of apparent liaison about the relevance of his sickle cell disease, insufficient consideration of additional monitoring, and gaps in the biopsy guidance and procedure for patients with conditions such as HbSS.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS ;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS ;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison between care teams about HbSS-relevant matters before liver biopsy
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out ;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS .
” Open source report
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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 Include the Prevention of Future Deaths report in the material considered during the next review of the liver biopsy guidance.
Verbatim wording from the response “This guidance was developed by the British Society of Gastroenterology in collaboration with the Royal College of Radiologists and Royal College of Pathology. At the time in which this guidance is due to be reviewed, we will facilitate expert radiological input, and we will specifically include your report in the material to consider.” Source location Response from Royal College of Radiologists
Open published response
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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 guidance need not specifically mention HbSS because it addresses broader groups of patients at increased bleeding risk and requires individualized risk-benefit judgment.
Verbatim wording from the response “Within the guidelines there is detailed consideration of the different possible technical approaches for liver biopsy and also consideration of where the procedure should occur. Management of the inherent risks is not explicitly referenced at each paragraph but is the underlying reason for these considerations to inform services and operators about the relevant factors when arriving at a decision, which will include many judgement calls and should be a process approached in partnership with their patients.” Source location Response from Royal College of Radiologists
Open published response
8 Aug 2024 Mrs Gillian Patricia Stokes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of clinical guidance for recognising possible radiation-induced sarcoma View source Failure to clearly communicate required follow-up to families View source Lack of protocols for first-line investigation of patients with breast implants after radiotherapy View source Failure to complete scheduled two-week follow-up after aspiration View source Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Gillian Patricia Stokes · 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
Mrs Gillian Patricia Stokes died from sarcoma of the right chest wall after previously receiving radiotherapy for breast cancer and having breast reconstructive surgery with an implant. The report raises concerns about insufficient guidance for identifying radiation-induced sarcoma and imaging the chest wall in patients with implants, the five-year surveillance period after breast cancer, and the failure to arrange a recommended two-week follow-up after aspiration.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance for recognising possible radiation-induced sarcoma
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma , or first line investigations for patients with breast implants to be able to see down to the chest wall. The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma ,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility .
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient .
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant. Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate required follow-up to families
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic. Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family . This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for first-line investigation of patients with breast implants after radiotherapy
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall . The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility.
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient.
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant . Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled two-week follow-up after aspiration
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic . Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family. This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer
Wider context from the report “(2) I have a concern regarding the current surveillance period of 5 years provided to patients with breast cancer considering the latency period of radiation induced sarcoma is 10 years .
” Open source report
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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 Direct the authors of the breast imaging guidance review to consider the identified concerns and all imaging modalities in the next version.
Verbatim wording from the response “The RCR does, however, produce other relevant guidance. In 2019, the RCR published the Guidance on screening and symptomatic breast imaging, fourth edition. This guidance is currently undergoing a review led by the British Society of Breast Radiology, which is an independent organisation and one of several Special Interest Groups within the RCR. Memoranda of Understanding with which the RCR works. As the next version is developed we have tasked the authors with considering the matters you have raised and also asked that all modalities are considered.” Source location Response from Royal College of Radiologists
Open published response
9 Feb 2024 Kazarie T’Calla Kwaku DWAAH-LYDER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of national guidance for investigating children with persistent symptoms after suspected ingestion of a non radio opaque object despite negative x-ray and fluoroscopy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kazarie T’Calla Kwaku DWAAH-LYDER · 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
Kazarie died after swallowing a googly eye in February 2022; the foreign body was not detected by x-ray or fluoroscopy, and he later became critically ill and was admitted to hospital in April 2023. The report raised concern about the lack of national guidance on investigating suspected swallowed non-radio-opaque foreign bodies when symptoms persist despite negative x-ray and fluoroscopy.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for investigating children with persistent symptoms after suspected ingestion of a non radio opaque object despite negative x-ray and fluoroscopy
Wider context from the report “It was suggested to me in evidence that children suspected of having swallowed a non radio opaque object such as a googly eye, whose symptoms (unlike Kazarie’s) persist, should undergo an endoscopy even if they have had a negative x-ray and fluoroscopy.
I was told that there is a lack of national guidance for such a situation. I appreciate that there are multiple considerations in planning investigations, such as the risks associated with CT scanning and the risks associated with the administration of a general anaesthetic. It seems that the matter would benefit from consideration at a national level.
” Open source report
1 Dec 2023 Ms Samantha Jade Shillito · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Unavailability of relevant specialist consultants in hospital View source Failure to communicate the seriousness and potential mortality of a patient's condition to family View source Failure to provide adequately informed consent for ascitic tap procedures View source Failure to escalate, assess and investigate NEWS-triggered deterioration View source Lack of quantified published evidence on ascitic tap risks View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ms Samantha Jade Shillito · 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
Ms Samantha Jade Shillito was significantly unwell when admitted to hospital and underwent an ascitic tap procedure that perforated an artery, causing intra-abdominal bleeding. She deteriorated over the following weekend without medical review or further investigations and died on 27 February 2022. Concerns included missed opportunities to respond to her deterioration, inadequate information about the risks of the procedure and shortcomings in communication with her family.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant specialist consultants in hospital
Wider context from the report “(1) There were no relevant specialist consultants in the hospital on the night of Friday 25/2/22, during Saturday 26/2/22 or on Sunday 27/2/22. Ms Shillito had a NEWS score which should have triggered an escalation of her treatment, but she was neither reviewed, examined properly or subjected to further investigations (such as blood tests and/or a CT scan) to establish the cause of her deterioration. Evidence was heard at the inquest from a consultant hepatologist to the effect that this was a missed opportunity to initiate remedial action when her deterioration could have been halted and her condition improved.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the seriousness and potential mortality of a patient's condition to family
Wider context from the report “(4) Ms Shillito’s family were not made aware of the seriousness of her underlying illness. No effective communication was provided to them even on Sunday 27 February to help them appreciate the gravity of her situation. Her husband and her mother informed the inquest that they had not been told that she might die. In consequence, the shock of her death on the evening of Sunday 27 February 2022 was all the greater. It is acknowledged that this concern did not contribute to Ms Shillito’s death, but it underlines the need for compassion and candour when dealing with patients and their families.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequately informed consent for ascitic tap procedures
Wider context from the report “(3) The practice at the hospital was to obtain verbal consent to the procedure from the patient in the minutes before it took place. A consultant radiologist acknowledged that the risk of death was not mentioned to Ms Shillito. It is questionable whether this can be considered to be a patient’s informed consent when the risks outlined are not reliably established, are not explained and the patient is not asked to sign a document. If there is a risk of death, irrespective of its rarity, the patient is entitled to be informed. This concern is heightened when one considers the patient’s medical condition and their likely emotional state, in circumstances which allow no time for reflection or discussion with other family members. It appears that no leaflet describing the ascitic tap procedure and the associated risks has been provided either by the Royal College of Radiologists or the hospital.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate, assess and investigate NEWS-triggered deterioration
Wider context from the report “(1) There were no relevant specialist consultants in the hospital on the night of Friday 25/2/22, during Saturday 26/2/22 or on Sunday 27/2/22. Ms Shillito had a NEWS score which should have triggered an escalation of her treatment, but she was neither reviewed, examined properly or subjected to further investigations (such as blood tests and/or a CT scan) to establish the cause of her deterioration. Evidence was heard at the inquest from a consultant hepatologist to the effect that this was a missed opportunity to initiate remedial action when her deterioration could have been halted and her condition improved.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of quantified published evidence on ascitic tap risks
Wider context from the report “(2) The ascitic tap procedure was said to be commonly undertaken and was regarded as low risk. The inquest was, however, unable to establish the magnitude of the risks of bleeding, infection or perforation of surrounding structures by reference to the medical literature or statistical evidence. How then can it be said to be a low-risk procedure if the inherent risks have not been quantified? This was viewed as a national (if not an international) problem, which requires published evidence to inform radiological practice.
” Open source report
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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 GMC’s comprehensive consent framework provides sufficient current principles for obtaining valid informed consent in radiology.
Verbatim wording from the response “The RCR archived its previous document Standards for patient consent particular to radiology (Second edition) in 2021, following the publication of the General Medical Council’s (GMC) updated guidance on decision making and consent. We fully endorse the GMC’s framework, which provides comprehensive and up-to-date principles for obtaining valid informed consent across all areas of medical practice, including radiology.” Source location Response from The Royal College of Radiologists
Open published response
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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 Producing patient information leaflets for individual procedures falls outside the RCR’s role as a professional standards body.
Verbatim wording from the response “Both BSGAR and BSIR have confirmed that they do not produce a specific patient information leaflet for ascitic drainage and the RCR does not produce patient information leaflets for individual procedures. This reflects our role as a professional body that sets and promotes standards of practice, rather than as a direct provider of patient-facing materials. However, BSIR has noted that the Cardiovascular and Interventional Radiological Society of Europe provides a general leaflet on fluid and abscess drainage procedures, which includes information on bleeding risks. BSIR also notes that there are numerous high-quality leaflets freely available through NHS trusts and related professional organisations. These typically include clear, evidence-based descriptions of procedure risks and are suitable for adaptation or local use.” Source location Response from The Royal College of Radiologists
Open published response
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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 national guidance adequately reflects the established risks of ascitic drainage, supported by standard ultrasound guidance.
Verbatim wording from the response “Our specialist interest groups emphasised that the risks of ascitic tap are well established and widely understood in current radiological practice. The use of ultrasound guidance has become standard and has been shown to further reduce complication rates. We therefore believe that the magnitude and nature of these risks are well defined in the published evidence base and are adequately reflected in existing national guidance.” Source location Response from The Royal College of Radiologists
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 Points 1 and 4 of the concerns are not directly relevant to the RCR’s remit or responsibilities.
Verbatim wording from the response “We note that points 1 and 4 in the matters of concern section of your report are not directly relevant to the remit or responsibilities of the RCR. Accordingly, our response focuses on matters 2 and 3.” Source location Response from The Royal College of Radiologists
Open published response
Concerns raised 2 Delays in Radiologist review of emergency chest x-rays View source Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Chantelle Reed · 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
Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after 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. The report was sent to Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Delays in Radiologist review of emergency chest x-rays
Wider context from the report “2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists . The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died . In an emergency situation such as this one, this delay represents on ongoing risk of future deaths .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw
Wider context from the report “1. The evidence of the independent expert in Emergency Medicine, was that “the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection . Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain . The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further ”. The expert felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms.
” Open source report
11 Aug 2020 Sylvia Scully · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar investigations View source Failure to use a Rapid Assessment and Treatment Model for walk-in Emergency Department patients View source Limited remote access to relevant systems for urgent out-of-hours imaging reporting View source Insufficient equipment for urgent out-of-hours imaging reporting from home View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sylvia Scully · 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
Sylvia Scully became unwell with sudden abdominal pain and vomiting and attended Tameside General Hospital on 9 February 2020. A radiologist initially reported another patient’s scan in error, and the correct diagnosis of hollow viscus perforation was made after her condition had deteriorated so severely that she could not withstand emergency surgery; she died in hospital on 10 February 2020. Concerns included variations in radiologists’ access to systems and equipment for out-of-hours reporting, the absence of a formal investigation into her care, and the lack of a Rapid Assessment and Treatment Model for walk-in emergency patients.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar investigations
Wider context from the report “1. Notwithstanding the circumstances of Mrs Scully’s death, the Trust’s routine clinical governance processes have not resulted in a formal Serious Untoward Incident investigation or similar taking place in respect of the care and treatment provided to her. This is a matter of concern given the great importance to patient safety of robust and effective investigations being undertaken in a timely fashion;
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to use a Rapid Assessment and Treatment Model for walk-in Emergency Department patients
Wider context from the report “2. A Rapid Assessment and Treatment Model was not in use at the Trust’s Emergency Department at the time of Mrs Scully’s attendance in respect of ‘walk-in’ patients . Such a paradigm would have seen Mrs Scully assessed early on by a senior doctor who had the experience and authority to promptly initiate all relevant investigations (including ordering CT Scans) and commence treatment, in advance of review by the surgical team.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Limited remote access to relevant systems for urgent out-of-hours imaging reporting
Wider context from the report “1. The court heard evidence that the Consultant Radiologist on-call for the Trust and reporting on urgent out-of-hours imaging from home, had more limited remote access to relevant systems than radiologists working for remote reporting companies and had been provided with less equipment than such an individual. Given the importance of effective out-of-hours reporting of imaging to emergency care, it is considered authoritative guidelines as to requisite access and recommended equipment could assist in reducing such variations.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient equipment for urgent out-of-hours imaging reporting from home
Wider context from the report “1. The court heard evidence that the Consultant Radiologist on-call for the Trust and reporting on urgent out-of-hours imaging from home, had more limited remote access to relevant systems than radiologists working for remote reporting companies and had been provided with less equipment than such an individual . Given the importance of effective out-of-hours reporting of imaging to emergency care, it is considered authoritative guidelines as to requisite access and recommended equipment could assist in reducing such variations.
” 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 Revisit radiology informatics guidance to verify that imaging equipment specifications are clear and unambiguous.
Verbatim wording from the response “The Royal College of Radiologists already has comprehensive guidelines available to all services detailing the minimum system specifications needed to review and report imaging investigations both on and off site. I have enclosed two relevant sets of guidelines which will assist all services in ensuring that the appropriate standards for the provision of IT equipment are met. These guidelines are publically available on our website and communicated to all our members and Fellows upon publication. In light of the concerns you have raised we have invited our Radiology Informatics Committee to revisit its guidance to double check that it is clear and unambiguous in its specifications, which the Committee has agreed to do.” Source location 2020-0156-Response-from-Royal-College-of-Radiologists.pdf
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 Local clinical governance protocols are responsible for ensuring imaging reports use equipment meeting minimum clinical requirements.
Verbatim wording from the response “Ultimately it is for local clinical governance protocols to ensure that radiologists and others involved in the reporting of imaging investigations, whether on or off site do so using equipment which meets minimum clinical requirements. Those minimum requirements are set out in publicly available guidelines available on our website.” Source location 2020-0156-Response-from-Royal-College-of-Radiologists.pdf
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 Publicly available guidelines already set minimum equipment requirements for reviewing and reporting imaging investigations on and off site.
Verbatim wording from the response “The Royal College of Radiologists already has comprehensive guidelines available to all services detailing the minimum system specifications needed to review and report imaging investigations both on and off site. I have enclosed two relevant sets of guidelines which will assist all services in ensuring that the appropriate standards for the provision of IT equipment are met. These guidelines are publically available on our website and communicated to all our members and Fellows upon publication. In light of the concerns you have raised we have invited our Radiology Informatics Committee to revisit its guidance to double check that it is clear and unambiguous in its specifications, which the Committee has agreed to do.” Source location 2020-0156-Response-from-Royal-College-of-Radiologists.pdf
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 Technology access issues are being addressed locally by Tameside General Hospital.
Verbatim wording from the response “The specific circumstances which gave rise to the matters of concern you raised to us were unclear and as such we sought clarification from Tameside General Hospital. We understand they are locally addressing the technology access issues pertinent to the circumstances of Mrs Scully’s death.” Source location 2020-0156-Response-from-Royal-College-of-Radiologists.pdf
Open published response
16 May 2016 Mr Critall · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 23 Minimal respiratory consultant documentation View source Outdated chest drain management protocol lacking complication actions View source Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence View source Excessive patient caseloads and unclear experience among senior resident medical staff View source Failure to document clinical examination View source Failure to complete consent detailing chest drain complications View source Failure to request repeat inflammatory markers View source Poor communication of the post-procedure care plan to ward staff View source Failure to use a WHO checklist for radiological interventions View source Proactive chest drain insertion without objective clinical evidence View source Absence of a documented management plan View source Failure to use real-time ultrasound guidance for chest drain insertion View source Failure to establish clinical necessity for chest drain insertion View source Lack of Acute or Basic Life Support training for the radiologist View source Reliance on emergency paramedic attendance to provide hospital care before transfer View source Insufficient nursing competence in resuscitation and chest drain management View source Lack of independent radiological indications for chest drain insertion View source Chest drain insertion decisions influenced by the day of the week View source Failure to radiologically confirm the position of a non-draining chest drain View source Failure to record observations before and after chest drain procedures View source Admission of acutely unwell patients without onsite HDU/ITU facilities View source Absence of operational protocols for hospital emergency situations View source Absence of HDU or ITU capability for hospital emergency situations View source See 20 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Critall · 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
Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Minimal respiratory consultant documentation
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission . There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Outdated chest drain management protocol lacking complication actions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
Wider context from the report “8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Excessive patient caseloads and unclear experience among senior resident medical staff
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72 . This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical examination
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to complete consent detailing chest drain complications
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications , radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to request repeat inflammatory markers
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Poor communication of the post-procedure care plan to ward staff
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to use a WHO checklist for radiological interventions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist , no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Proactive chest drain insertion without objective clinical evidence
Wider context from the report “9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented management plan
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place , no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to use real-time ultrasound guidance for chest drain insertion
Wider context from the report “5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’ . I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony).
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clinical necessity for chest drain insertion
Wider context from the report “3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of Acute or Basic Life Support training for the radiologist
Wider context from the report “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Reliance on emergency paramedic attendance to provide hospital care before transfer
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Lack of independent radiological indications for chest drain insertion
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant , a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Chest drain insertion decisions influenced by the day of the week
Wider context from the report “4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week .
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to radiologically confirm the position of a non-draining chest drain
Wider context from the report “6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining . I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s death.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations before and after chest drain procedures
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Admission of acutely unwell patients without onsite HDU/ITU facilities
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration . The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Absence of operational protocols for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report × 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 Royal College of Radiologists; that does not assign responsibility.
PFD Monitor interpretation Absence of HDU or ITU capability for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” Open source report
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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 Make Fellows and members aware of the BTS Pleural Disease Guideline 2010 Quick Reference Guide.
Verbatim wording from the response “In the light of your report, we are taking steps later this month to make our Fellows and members aware once again of these important guidelines.” Source location 2016-0187-Response-by-Royal-College-of-Radiologists
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations