Source · Prevention of Future Deaths

Nicola Marsden

Ref: 2014-0373 Date: 14 Aug 2014 Responses identified: 0 / 1 View PDF

A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for specialist interpretation and requiring a review of current protocols.

Date 14 Aug 2014
56-day deadline 9 Oct 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for specialist interpretation and requiring a review of current protocols.
View full coroner's concerns
That during the course of the evidence I was told that the brain scan relating to the deceased was mis-interpreted. The CT scans were viewed by a Radiologist and not Neuro-Radiologist; despite the fact that there is Guideline for the scans viewed by a Neuro-Radiologist at Addenbrooke s Hospital. My. concern is that the interpretation of neurological scans and brain scans should be viewed and reported by Neuro-Radiologists and perhaps the Protocol for of scans by non-specialists should be reviewed ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you, as the Chief Executive of NHS England, have the power to take such action YOUR RESPONSE You are under a to respond to this Report within 56 of the date of this report; namely by 9th October 2014; I, the Coroner; may extend the period_ Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my Report to: the Chief Coroner 17th having viewing duty days and to the following Interested Person(s): husband Iam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both; in complete or redacted Or summary form_ He may send a COpY of this Report to any person who he believes may find it useful or of interest. You may make representations to me; the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner Dated this 14th day of August 2014 (huu Tom OSBORNE Senior Coroner Bedfordshire & Luton M

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Report details

Reference
2014-0373
Date of report
14 August 2014

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Oct 2014 (estimated).

Sent to

NHS England

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