31 Mar 2026 Raisa Cristina Iordan · Prevention of Future Deaths report West Yorkshire Western
View report summary
Concerns raised 5 Failure to provide adequate clinical assessment View source Delays in obtaining scans due to insufficient on-call staffing View source Lack of trained support for paediatric emergency intubation View source Lack of paediatric radiology expertise in out-of-hours imaging interpretation View source Failure to consider concerns raised by other clinicians View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Increase prospective second reading for high-risk paediatric CT brain examinations, particularly for specified under-five neurological, infection, or safeguarding presentations.
View source
Action
Conduct retrospective senior-consultant second readings of all paediatric CT examinations within the same shift and monitor capacity constraints.
View source
Action
Encourage structured standard reports for CT head examinations to support systematic assessment of key infant imaging features.
View source
Action
Roster a senior radiologist on every emergency shift for immediate peer consultation, second opinions, clinical discussion, and escalation support.
View source
Action
Share governance learning within the Emergency Radiology service on infant CT limitations and explicit escalation advice.
View source
Action
Engage the client about service needs and discuss whether introducing or expanding prospective double reading would benefit its service.
View source
Action
Review the effectiveness of second-reading processes and escalation pathways during 2026 and report findings through clinical governance.
View source
Action
Formally recognise scope-of-practice limitations and encourage radiologists to state when subspecialist review or further imaging is recommended.
View source
Action
Provide prospective double reading for all paediatric CT scans involving children aged 0–5 years.
View source See 6 more actions
×
AI-generated summary
Raisa Cristina Iordan · 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
Raisa Cristina Iordan became less responsive and developed seizures and severe neurological symptoms after returning to Dewsbury District Hospital with a suspected viral illness. She was later transferred to Sheffield Children’s Hospital, where imaging showed catastrophic and irreversible brain herniation, and her death was confirmed on 30 November 2023. Concerns included missed escalation of care, inaccurate interpretation of imaging by an external general radiologist without paediatric radiology experience, and delays in scanning and intubation.
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 Telemedicine Clinic Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clinical assessment
Wider context from the report “1) Concerns were raised by a Junior Doctor in respect of Raisa's presenting symptoms, which were ignored by the more Senior Doctor in charge, whose assessment of Raisa was limited and of poor quality . The more Senior Doctor formed a view that Raisa was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for Raisa during the course of her admission.
” 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 Telemedicine Clinic Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining scans due to insufficient on-call staffing
Wider context from the report “3) There were delays in obtaining a scan for Raisa as there was only one on call anaesthetist at Dewsbury and one on call radiographer . The scan was required prior to Raisa being transferred as the treating clinicians needed to ensure that not only was it safe for Raisa to be transferred but also that she was being transferred to a hospital that was able to provide appropriate care, there being no paediatric intensive care unit at Pinderfields 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 Telemedicine Clinic Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of trained support for paediatric emergency intubation
Wider context from the report “4) There were delays in Raisa being intubated as there was no support for the on call anaesthetist , with no Operating Department Practitioner or other trained member of staff to help manage a critically ill paediatric patient .
” 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 Telemedicine Clinic Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric radiology expertise in out-of-hours imaging interpretation
Wider context from the report “2) Since September 2021, the standard practice across the Mid Yorkshire Teaching NHS Trust has been that the interpretation of out of hours radiology is provided by an external agency, Telemedicine Clinic Limited ("TMC"). The company provides radiology reporting services to a large number of hospitals, providing, amongst other things, acute on call radiology reporting services. Although TMC has a number of radiologists available from a variety of subspecialties to provide reports, their expertise are limited to that of adult radiology, rather than paediatric radiology . At the time the scan was undertaken, the radiographer raised concerns that the imaging appeared abnormal and contacted TMC to ensure that no further imaging was required and in the course of that conversation, concerns were raised in respect of raised intracranial pressure. When the images were reported by TMC, it was said that there was no convincing evidence of acute intracranial pathology , but when Raisa's imaging was reviewed at Sheffield Children's Hospital, it was noted that there was obvious brain herniation which had not been identified by the general radiologist at TMC .
” 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 Telemedicine Clinic Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider concerns raised by other clinicians
Wider context from the report “1) Concerns were raised by a Junior Doctor in respect of Raisa's presenting symptoms, which were ignored by the more Senior Doctor in charge , whose assessment of Raisa was limited and of poor quality. The more Senior Doctor formed a view that Raisa was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for Raisa during the course of her admission .
” 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 Increase prospective second reading for high-risk paediatric CT brain examinations, particularly for specified under-five neurological, infection, or safeguarding presentations.
Verbatim wording from the response “1) TMC commits to progressively increasing, prospective second reading for high-risk paediatric CT brain examinations, particularly in children under 5 years with neurological symptoms, infection or safeguarding concerns.” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct retrospective senior-consultant second readings of all paediatric CT examinations within the same shift and monitor capacity constraints.
Verbatim wording from the response “Following this adverse incident, TMC has implemented and reinforced the following measures:” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage structured standard reports for CT head examinations to support systematic assessment of key infant imaging features.
Verbatim wording from the response “Following this adverse incident, TMC has implemented and reinforced the following measures:” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roster a senior radiologist on every emergency shift for immediate peer consultation, second opinions, clinical discussion, and escalation support.
Verbatim wording from the response “Following this adverse incident, TMC has implemented and reinforced the following measures:” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share governance learning within the Emergency Radiology service on infant CT limitations and explicit escalation advice.
Verbatim wording from the response “6) This case has been reviewed through TMC’s Serious Adverse Event and governance processes. Learning points have been shared within the Emergency Radiology service, with emphasis on the limitations of CT in infants and the importance of explicit escalation advice where uncertainty exists.” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage the client about service needs and discuss whether introducing or expanding prospective double reading would benefit its service.
Verbatim wording from the response “2) TMC will engage with its client to better understand their individual service needs and any challenges they may be facing, and to discuss whether the introduction or expansion of prospective double reading would be of benefit to them.” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the effectiveness of second-reading processes and escalation pathways during 2026 and report findings through clinical governance.
Verbatim wording from the response “4) Paediatric emergency imaging already forms part of TMC’s rolling audit programme. Effectiveness of second-reading processes and escalation pathways will be reviewed during 2026, with findings reported through clinical governance structures.” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formally recognise scope-of-practice limitations and encourage radiologists to state when subspecialist review or further imaging is recommended.
Verbatim wording from the response “3) Scope-of-practice limitations are formally recognised, and radiologists will be encouraged to clearly state when subspecialist review or further imaging (e.g. MRI) is recommended.” Source location Response from Telemedicine Clinic Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide prospective double reading for all paediatric CT scans involving children aged 0–5 years.
Verbatim wording from the response “Following this adverse incident, TMC has implemented and reinforced the following measures:” Source location Response from Telemedicine Clinic Limited
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 General consultant radiologists supported by governance and escalation safeguards are considered appropriate; complete elimination of paediatric imaging risk is not expected.
Verbatim wording from the response “TMC considers it important to place its response within the wider national context, which was also highlighted during the inquest. There is a recognised national challenge in accessing subspecialist paediatric neuro-radiology expertise, particularly outside normal working hours, even in tertiary paediatric centers. As a result, emergency paediatric imaging services across the UK NHS are commonly delivered by general consultant radiologists, supported by clinical governance frameworks and escalation pathways. This model is explicitly recognised by the Royal College of Radiologists (RCR) as appropriate where such safeguards are in place.” Source location Response from Telemedicine Clinic Limited
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations