Raymond Leake

“During the evidence it was heard that efforts were made to review why the scan was missed. No exact reason was found, and it was believed likely human error. It was acknowledged that a number of processes had been put into place in March in an effort to improve the radiology scanning processes including training, markers and portering; however, the audit of these new processes was still not completed by the time Mr [name redacted] death came to inquest. I was informed the believed reason for not reviewing the audit was staff numbers. This meant that I could have no reassurance that these processes are working appropriately or that further urgent scans would not be missed in future.”