3 Apr 2020 Andrew Spencer Wing · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review View source Insufficiently detailed clinical information for radiographer X-ray reviews View source Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis View source
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. 1
Action
Ensure Society of Radiographers members are informed of the approved Clinical Imaging Board guidance on employer and referrer responsibilities under IR(ME)R 17.
View source
×
AI-generated summary
Andrew Spencer Wing · 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
Andrew Spencer Wing had a history of untreated hypertension and was discharged from hospital after investigations for acute left-sided pain, without a CT aorta being undertaken. He subsequently died from the effects of an aortic dissection. The principal concerns were that the chest X-ray and recognised possibility of aortic dissection should have led to a CT aorta, and that radiographers reviewing X-rays were given sparse clinical information.
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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Failure to provide radiographers with the differential diagnosis when requesting remote X-ray review
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection . If he had been made aware of this he would have advised that a CT Aorta be 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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed clinical information for radiographer X-ray reviews
Wider context from the report “2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.
” 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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis
Wider context from the report “1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken . Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken.
” 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 Ensure Society of Radiographers members are informed of the approved Clinical Imaging Board guidance on employer and referrer responsibilities under IR(ME)R 17.
Verbatim wording from the response “The SoR works in partnership with the Royal College of Radiologists and the Institute of Physics and Engineering in Medicine to promote understanding of IR(ME)R 17. We do this through a collaborative body, the Clinical Imaging Board. New guidance is currently in preparation and is expected to be approved in the near future. This will include the responsibilities of employers and referrers under the legislation. The following extract is from an advanced draft:” Source location 2020-0089-Response-from-the-Society-of-Radiographers_Redacted
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 Employers, rather than the Society, have overarching responsibility for ensuring referrers are trained in IR(ME)R 17 requirements.
Verbatim wording from the response “In the case of Mr Wing, the clinician that referred him for the chest x-ray should have been aware of the requirements to provide sufficient clinical information to justify the procedure and to enable a diagnostic report to be subsequently made. The employer has an over-arching responsibility to ensure all referrers within their authority are trained in the requirements of IR(ME)R 17.” Source location 2020-0089-Response-from-the-Society-of-Radiographers_Redacted
Open published response
7 Dec 2017 Mrs Violet Levine Nelson · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Failure to oversee or verify ultrasonography reports by a Consultant Radiologist View source Ultrasound reports failing to carry appropriate recommendations to referring clinicians View source Lack of General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Violet Levine Nelson · 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 Violet Nelson collapsed suddenly at home and died on 17 September 2016; a post-mortem examination identified a ruptured thoracic aortic aneurysm. The report raised concerns that earlier ultrasound findings were not overseen by a Consultant Radiologist and did not recommend referral to a Vascular Surgeon or CT examination, and that GPs may not have been aware of the significance of a suprarenal aortic aneurysm.
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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Failure to oversee or verify ultrasonography reports by a Consultant Radiologist
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist , it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon.
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future.
” 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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Ultrasound reports failing to carry appropriate recommendations to referring clinicians
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon.
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future.
” 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 The Society and College of Radiographers; that does not assign responsibility.
PFD Monitor interpretation Lack of General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon .
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations