Peter Harris
20 Jul 2023 · Coroner Alison Hewitt · City of London
The coroner's concerns
1. delayed diagnosis of cancer
“The evidence at the inquest showed that the results of two separate scans performed on the Deceased, both of which had concerning outcomes, were not seen and acted upon in a timely manner.”
2. unread radiology reports
“The new electronic system is introducing a "read receipt" feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner”
Responses
2023-0260-Response-from-Barking-Havering-and-Redbridge-University-Hospitals.pdf ↗· Barking
Stated action · 17 May 2023
“The Radiology department will alert/notify the referrer's/requesters to all imaging with: a. Expected, Unexpected, or Newly Detected Cancer b. Unexpected Critical or Significant Non-Cancer Findings. The referrer/requester will be notified with either a CANCER alert for the expected, unexpected, or newly detected cancer and cancer recurrence, or CRITICAL alert for expected or unexpected findings. This will be sent electronically via Aptvision2 to the referrer/requester (*Verbal Escalation is”
Stated action · 30 October 2023
“Aptvison Radiology Referral System - this new Radiology Requesting System is planned to live week commencing 30 October 2023. 2. Acknowledgement Feature - Following a finalised radiological report, alongside any urgent notifications produced by radiology, an”
Stated action
“Viewable WorkLists - It is planned that a viewable worklist of requested imaging and radiological report by referring location /area will be available in the initial release of the referral portal. A secondary release is planned to allow consultants/referrers to view a worklist based who was involved in the requesting process e.g., individual consultant or a group of named team members. 4. Oversight of Reporting - Speciality Specific Reports - Requesting Specialties will be provided with direct”
Stated action
“Speciality Specific Mailboxes - will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty. 6. Chief Medical Officer [name redacted] - To facilitate prompt review, acknowledgement, and action on all imaging reports by referrers. The CMO (or nominated deputy) will inform each CG of the requirement that each of”
Stated action
“The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO. 7. Collaborative Working - On 04 July 2023 Dr [name redacted], Consultant [name redacted] and Clinical Lead for Radiology, presented the BHRUT's Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group's membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps”