Sharon Reeve

1. 1. inappropriate referral to neurosurgical unit

   “The two consultant radiologists at the district general hospital saw a need for a 1 specialist opinion to assist in the interpretation of complex and abnormal CT and MRI scans. There was no clear prescribed pathway for them to obtain direct access to neuroradiologists at the tertiary centre. In consequence, an inapposite referral was made to a neurosurgical unit, which did not assist the resolution of the uncertainties regarding the correct diagnosis. My concern is that if much needed linkages”

2. 2. miscommunication causing delayed treatment

   “Communications between the clinicians at the district general hospital ('DGH') and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient's condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists”

3. 3. unclear electronic referral portal usage

   “Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: - (a) Make plain the circumstances in which it should be used - and where it is not appropriate. (b) The information required to be included. (c) The precise issues upon which guidance is sought.”

No published response was found on judiciary.uk.