Source · Prevention of Future Deaths

Andrew Wing

Ref: 2020-0089 Date: 3 Apr 2020 Coroner: Caroline Topping Area: Surrey Responses identified: 2 / 3 View PDF

A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for accurate diagnosis.

Date 3 Apr 2020

56-day deadline 15 Jun 2020 est.

Responses identified 2 of 3

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The evidence showed that:
1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken.
2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.

Responses

2 respondents

the General Medical Council Regulator / Inspectorate

27 May 2020 PDF

Noted

The General Medical Council acknowledges the concerns and has forwarded the report to their Employer Liaison Adviser to discuss with the Trust. If the Trust identify any individual clinicians whose fitness to practise may be impaired, they will refer to the GMC. (AI summary)

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Dear Miss Topping Mr Andrew Spencer Wing (Deceased) General Medical Council Regent's Place 350 Euston Road London NW1 3JN Email: gmc@gmc-uk.org Website: www.gmc-uk.org Telephone: 0161 923 6602 Chair Dame Clare Marx Chief Executive and Registrar Charlie Massey I am writing to you following receipt of the Regulation 28 Report dated 3 April
2020. I am sorry to hear about the death of Mr Andrew Spencer Wing and I am grateful to you for bringing this to my attention. I have noted the contents of the report and have forwarded this matter to our Employer Liaison Adviser to discuss with the Trust. If the Trust identify any individual clinicians whose fitness to practise may be impaired, they will refer to us to consider in line with our usual procedures. Please do feel free to contact me if you would like to discuss this further.

the Society of Radiographers Other

PDF

Noted

The Society of Radiographers acknowledges the coroner's concerns and highlights the importance of referrers providing sufficient clinical information under the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 17). They are working with other bodies to promote understanding of IR(ME)R 17 and new guidance is in preparation. (AI summary)

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Dear Ms Topping

Re Regulation 28 Report: Andrew Spencer Wing

Thank you for contacting the Society of Radiographers (SoR) in connection with the inquest following the death of Andrew Spencer Wing, concluded on 6th March this year. I am the current President of the SoR, having taken over the role from in July 2019. We note your concerns that appropriate actions might help avoid future deaths in similar circumstances. The SoR is pleased to provide the following perspectives and actions. The Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 17) is the legislative framework governing all clinical imaging that uses x-rays. The regulations stipulate the legal requirements for all aspects of any x-ray procedure, including the responsibilities surrounding referral of a patient for imaging.

In the case of Mr Wing, the clinician that referred him for the chest x-ray should have been aware of the requirements to provide sufficient clinical information to justify the procedure and to enable a diagnostic report to be subsequently made. The employer has an over-arching responsibility to ensure all referrers within their authority are trained in the requirements of IR(ME)R 17.

From your report it seems likely that the referral for Mr Wing to have a chest x-ray did not include the details of the differential diagnosis of dissecting aortic aneurysm. Had these details been included, the radiographers involved in taking the chest x-ray and in providing the clinical report could have recommended further imaging, including the CT scan which could have provided a more definitive diagnosis.

The SoR works in partnership with the Royal College of Radiologists and the Institute of Physics and Engineering in Medicine to promote understanding of IR(ME)R 17. We do this through a collaborative body, the Clinical Imaging Board. New guidance is currently in preparation and is expected to be approved in the near future. This will include the responsibilities of employers and referrers under the legislation. The following extract is from an advanced draft:

Referrer The referrer must be a registered healthcare professional (10) as defined in IR(ME)R. In Northern Ireland, this also includes medical practitioners registered with the Medical Council of Ireland.

Report sections

Investigation and inquest

An inquest into the death of Andrew Spencer Wing was opened on 23rd May 2019 and resumed on the 2nd April 2020 and concluded on 6th March 2020 I concluded with a narrative conclusion that: Andrew Wing suffered an acute onset of pain in his chest at 1am on the 13th January 2019. He attended at St Peter’s Hospital, Chertsey at 16.47 where he was seen in the minor injuries department by which time his pain had diminished and presented as mild. He underwent investigations which ruled out a myocardial infarction. An aortic dissection was one of the differential diagnoses the possibility of which was recognised and for which the necessary diagnostic investigation was a CT Aorta. Despite the index of suspicion being sufficient to require this to be undertaken it was not and had it been it would have identified an aortic dissection. He was discharged and died from the effects of the aortic dissection on the 15th January 2019 at the Ship Hotel in Weybridge. Had a dissection been identified on the 13th January 2019 prior to discharge he would have been subject to the necessary emergency surgery which he would have survived.

The cause of death was : 1a Haemopericardium 1b Aortic Dissection 1c Hypertension

I concluded with the narrative conclusion set out above.

Circumstances of the death

Andrew Wing had a long history of untreated hypertension having refused medication for the condition. In the early hours of the 13th January 2019 he suffered an acute onset of severe pain in his left side. He attended St Peter’s Hospital, Chertsey by which time the pain had diminished. He underwent investigations, an ECG, Chest Xray and blood tests. The blood tests did not show a rise in troponin levels. The Chest Xray was read by 2 emergency clinicians who thought it appeared normal. He was discharged from hospital and died on the 15th January 2020 from the effects of the aortic dissection. Aortic dissection was one of the differential diagnoses considered but a CT Aorta was not undertaken.

Copies sent to

St Peter’s Hospital, Chertsey

Similar PFD reports

Shared signals

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Report details

Reference: 2020-0089
Date of report: 3 April 2020
Coroner: Caroline Topping
Coroner area: Surrey

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jun 2020 (estimated).

Sent to

College and Society of Radiographers

General Medical Council

Royal College Emergency Medicine

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.