Recurance · prevention of future deaths reports
Pre-inquest brief
Missing radiology discussion records for children
The earlier warning
Jacob Owczarek · 28 Jul 2021 · Dr Elizabeth Didcock, Nottinghamshire
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
judiciary.uk/…/jacob-owczarek-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Jacob Owczarek (28 Jul 2021) · stated timescale: Q3 pilot
“A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used.”
judiciary.uk/…/2021-0259-Response-from-Doncaster-and-Bassetlaw-…
What recurred
- 25 Feb 2025 · Khadija Kerri · Louise Slater · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Jacob Owczarek · 28 Jul 2021
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
Later · Khadija Kerri · 25 Feb 2025
“There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team.”
What happened next
No web check of the stated actions has been published for this chain.