Kathleen Stewart
17 Jul 2022 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. failure to act on abnormal radiology report
“It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs [name redacted] did not receive the indicated follow up of analgesia and referral for physiotherapy”
2. lack of systemic investigation into report non-action
“It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case”
3. potential systemic failure in imaging report handling
“Consider the fitness for purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging”
Responses
2022-0213-Response-from-NHS-Tameside-and-Glossop-Integrated-Care.pdf ↗· Tameside and Glossop Integrated Care NHS Foundation Trust
Stated action · end of September 2022
“The Trust has in place a system whereby a RadiologistorR~porting Radiographerreviewsand reports on all X-Rays which have been requested from the Emergency Department. Where the request for an X-Ray is made by a member of the Emergency Department Team, the report is shared for Emergency Department Consultant review and, where appropriate, further action is undertaken. At the time Mrs [name redacted] was treated in the Emergency Department there were reports within the Emergency Department awaiting Consultant”