PFD report

Akash Dinesh Bhudia · Prevention of Future Deaths report

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Issued 18 May 2023•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of a process for adding alerts to normal communication methods for significant radiological findings
    Part of recurring concern: Failure to communicate clinically significant diagnostic findings to patients and care providers
  2. Failure to highlight significant, unexpected, and important radiological findings to the referring clinician
    Part of recurring concern: Failure to communicate clinically significant diagnostic findings to patients and care providersPart of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable radiology processes for communicating findings and initiating required follow-up
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Circulate the updated Medica Alerts policy to all reporters.

    Stated by MedicaStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.
  2. Action

    Raise Urgent Findings for relevant cases until clients adjust their internal alert processes.

    Stated by MedicaStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.
  3. Action

    Work with clients to enact the 2022 Academy of Royal Colleges and RCR Alerts guidelines within local processes.

    Stated by MedicaStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.

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

  1. Position

    Clients are responsible for integrating the 2022 Alerts guidelines into local processes; until then, Medica will raise Urgent Findings.

    Stated by MedicaRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a process for adding alerts to normal communication methods for significant radiological findings

Wider context from the report

“The X ray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up X ray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner. The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically significant diagnostic findings to patients and care providers.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to highlight significant, unexpected, and important radiological findings to the referring clinician

Wider context from the report

“The X ray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up X ray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner. The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically significant diagnostic findings to patients and care providers; Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable radiology processes for communicating findings and initiating required follow-up.

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

Circulate the updated Medica Alerts policy to all reporters.

Verbatim wording from the response

“This new policy has been circulated to all reporters and a communication from me has highlighted the findings of the inquest to all reporters.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

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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

Raise Urgent Findings for relevant cases until clients adjust their internal alert processes.

Verbatim wording from the response

“Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

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

Work with clients to enact the 2022 Academy of Royal Colleges and RCR Alerts guidelines within local processes.

Verbatim wording from the response

“Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

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

Update the Medica Alerts policy to require urgent notification of referrers for potential new TB diagnoses and advise that treatment changes may be needed.

Verbatim wording from the response

“Since the inquest Medica have edited the Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers. The alert and the report should advise the referrer that a change of treatment may be required.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

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

Clients are responsible for integrating the 2022 Alerts guidelines into local processes; until then, Medica will raise Urgent Findings.

Verbatim wording from the response

“Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Communicate the inquest findings to all reporters.

    Stated by MedicaStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The referrer is responsible for reading and acting appropriately on imaging reports under IRMER 2017.

    Stated by MedicaRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The chest X-ray was reported in a standard way because findings were nonspecific, no TB red flags were provided, and other pathogens were possible.

    Stated by MedicaDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Communicate the inquest findings to all reporters.

Verbatim wording from the response

“This new policy has been circulated to all reporters and a communication from me has highlighted the findings of the inquest to all reporters.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The referrer is responsible for reading and acting appropriately on imaging reports under IRMER 2017.

Verbatim wording from the response

“• Section 5. At the time of the CXR in question, I would consider Akash to have been under the care of his GP. My comment regarding a clinical team was meant to indicate primary, secondary and tertiary care if there is an element of active management/follow up. IRMER 2017 regulations place onus on the referrer to read and act appropriately on imaging reports of studies they have initiated.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The chest X-ray was reported in a standard way because findings were nonspecific, no TB red flags were provided, and other pathogens were possible.

Verbatim wording from the response

“• Section 5. The CXR was reported in a way that raised the possibility of atypical pneumonia. At the time of reporting the CXR the reporter had no knowledge of the additional information available in the court, there were no red flag symptoms for TB given in the clinical request and the CXR findings could have been caused by a number of pathogens including TB and COVID amongst others including fungi and less common bacteria. Therefore, the X-ray was reported in what I would consider a standard way.”

Source location

Response from Medica Group
Page 1 · response
Published 19 May 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026