South Tyneside and Sunderland NHS Foundation Trust
NHS / Health Body
Action Taken
South Tyneside and Sunderland NHS Foundation Trust has shared learning with radiologists about the importance of thorough searches, awareness of confirmation bias, and comparing prior relevant imaging. They are updating induction training and developing a Standard Operating Procedure with 4Ways for radiology reporting. (AI summary)
View full response
Dear I \ Regulation 28 Report to Prevent Future Deaths - Mrs Anne Lorraine Dyson I write in response to your Report to Prevent Future Deaths, dated 26 August2025, following the sad death of Anne Dyson. I note that your concerns in this matter relate to processes around sharing relevant clinical information with Radiologists and the potential impact this has on the interpretation of imaging As a Trust we have taken Anne Dyson's death very seriously and as you heard at the inquest, we:have taken steps to share the identified learning with relevant Radiologists within the Trust, highlighting the importance of Radiologists being satisfied with the extent of their search, being aware of the risk of confirmation bias and the importance of comparing prior qelevant' imag ing, where appropriate. Followiirg receipt of your Report to Prevent Future Deaths, the Trust has reviewed existing radiology processes, in liaison with 4Ways, who are an external iadiology repgrting partner of the Trust, to consider how we can strengthen current processes both internally and externally The Trust's Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide corhmunication to update current staff members and there will be a regular audit of these standards, completed by the Trust's Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate. ellence .{ in all that we do
A Standard Operating Procedure (SOP) is also being developed between the Trust and 4Ways, which is currently going through internal review and sign off, to provide a more clearly defined clinical process for both Trust and 4Ways Radiologists, around the reporting of images to ensure that there is a consistent approach amongst clinicians, with them being aware of their own responsibilities. As part of this SOP, clinicians are reminded of the need, where clinically relevant, to compare previous imaging, with the requirement to now include reference to either a new finding or mark that no other changes are noted, to make it clear that a comparison of relevant images has taken place. I hope that the above addresses your concerns, but please do revert back to me should you have any further comments or queries that I can assist with.
A Standard Operating Procedure (SOP) is also being developed between the Trust and 4Ways, which is currently going through internal review and sign off, to provide a more clearly defined clinical process for both Trust and 4Ways Radiologists, around the reporting of images to ensure that there is a consistent approach amongst clinicians, with them being aware of their own responsibilities. As part of this SOP, clinicians are reminded of the need, where clinically relevant, to compare previous imaging, with the requirement to now include reference to either a new finding or mark that no other changes are noted, to make it clear that a comparison of relevant images has taken place. I hope that the above addresses your concerns, but please do revert back to me should you have any further comments or queries that I can assist with.