Recipient

Telemedicine Clinic Limited

First report 31 Mar 2026•Latest report 31 Mar 2026

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 10

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

100%published responses found

10stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

31 Mar2026
West Yorkshire Western
Concerns raised5
1. Failure to provide adequate clinical assessment
2. Delays in obtaining scans due to insufficient on-call staffing
3. Lack of trained support for paediatric emergency intubation
1. Lack of paediatric radiology expertise in out-of-hours imaging interpretation
2. Failure to consider concerns raised by other clinicians
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Increase prospective second reading for high-risk paediatric CT brain examinations, particularly for specified under-five neurological, infection, or safeguarding presentations.
  Stated in progress
2. Action
  Conduct retrospective senior-consultant second readings of all paediatric CT examinations within the same shift and monitor capacity constraints.
  Stated completed
3. Action
  Encourage structured standard reports for CT head examinations to support systematic assessment of key infant imaging features.
  Stated completed
1. Action
  Roster a senior radiologist on every emergency shift for immediate peer consultation, second opinions, clinical discussion, and escalation support.
  Stated completed
2. Action
  Share governance learning within the Emergency Radiology service on infant CT limitations and explicit escalation advice.
  Stated completed
3. Action
  Engage the client about service needs and discuss whether introducing or expanding prospective double reading would benefit its service.
  Stated planned
4. Action
  Review the effectiveness of second-reading processes and escalation pathways during 2026 and report findings through clinical governance.
  Stated planned
5. Action
  Formally recognise scope-of-practice limitations and encourage radiologists to state when subspecialist review or further imaging is recommended.
  Stated completed
6. Action
  Provide prospective double reading for all paediatric CT scans involving children aged 0–5 years.
  Stated completed
Respondent positions 1
1. Position
  General consultant radiologists supported by governance and escalation safeguards are considered appropriate; complete elimination of paediatric imaging risk is not expected.
  Existing arrangements considered sufficient
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
Page 2 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 3 · response
Published 7 April 2026
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
Page 3 · response
Published 7 April 2026
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
Page 2 · response
Published 7 April 2026
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
Page 1 · response
Published 7 April 2026
Open published response

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to provide adequate clinical assessment

Delays in obtaining scans due to insufficient on-call staffing

Lack of trained support for paediatric emergency intubation

Lack of paediatric radiology expertise in out-of-hours imaging interpretation

Failure to consider concerns raised by other clinicians

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 9

Respondent positions 1