Recurance · prevention of future deaths reports
Pre-inquest brief
Missed CT scan authorisation and delayed staging scans
The earlier warning
Pamela Moran · 12 Nov 2019 · Aled Gruffydd, Swansea Neath & Port Talbot
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
judiciary.uk/prevention-of-future-death-reports/pamela-moran
What was promised
No published response from ABMU Health Board was found for the earlier reports.
What recurred
- 28 Jul 2025 · Gareth Tatchell · Aled Gruffydd · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Pamela Moran · 12 Nov 2019
“There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.”
Later · Gareth Tatchell · 28 Jul 2025
“Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irresectable.”
What happened next
No web check of the stated actions has been published for this chain.