Roger Ballard
24 May 2021 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. unclear scan reporting and recording
“The inquest heard evidence that the way in which the scan was reported and then recorded was not clear and contributed to the treating clinician not appreciating the scan findings.”
2. lack of documentation of clinical decisions
“The documentation regarding clinical decisions taken including the decision to not follow the advice of the neurosurgeons was not documented in the notes. It was unclear if there was an expectation that where clinicians took a decision contrary to such advice how and in what detail the rationale should be recorded within the notes.”
Responses
2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published.pdf ↗· Tameside and Glossop Integrated Care NHS Foundation Trust
Stated action
“The Trust has been developing a Results Governance Tracker, which has already been implemented in one major area of the Trust. It is anticipated that this roll-out will continue, although it did unfortunately experience some delays due to the pandemic. Once this Tracker is Trust-wide, it will ensure that all Pathology and Radiology results will have to be acknowledged as read on the PACS system within a specified timeframe.”