DHSE NHS England
Action Planned
AI-generated response summary
• The Integrated Care Boards will ask provider organisations to review current escalation pathways and assurance processes for out-of-hours imaging interpretation. • The Integrated Care Boards will seek assurance that escalation pathways for consultant radiologist input out of hours are clear and understood. • The Integrated Care Boards will seek assurance that arrangements support timely access to senior radiological expertise for complex cases.
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Dear Mr Covell, Thank you for your Prevention of Future Death Report dated 26 May 2026 following the inquest into the death of Mr Cleave. Firstly, I would like to express my sincere condolences to Mr Cleave’s family. The circumstances described in the inquest are tragic and we are grateful for the opportunity to consider the concerns you have raised. The concern identified in your report relates to the availability of consultant radiologist expertise outside normal working hours across Devon hospitals and the potential impact this may have on the interpretation of complex imaging studies requiring consultant-level review. Following receipt of your report, NHS Devon and NHS Cornwall and Isles of Scilly Integrated Care Boards sought clarification within Devon and Cornwall regarding current out-of-hours radiology arrangements. The information provided confirms that consultant radiologist cover is available 24 hours a day. In Torbay and South Devon NHS Foundation Trust consultant radiologists are working on site 0800-2200 and through formal on-call arrangements overnight. Whilst consultant radiologists are not routinely resident within radiology departments overnight, consultant radiologists remain available outside normal working hours and can be contacted for advice, review and support when clinically required. We have been advised that:
• Consultant radiologists are available at all times across the acute trusts within Devon and the wider Peninsula network.
• Overnight imaging is reported by appropriately trained radiology registrars operating within defined competency frameworks and governance arrangements.
• Escalation processes exist overnight to enable registrars and treating clinicians to seek consultant radiologist input where cases are complex, findings are uncertain, or urgent specialist advice is required.
2
• There is a formal process of next day review of overnight imaging reported by registrars aligned with the Peninsula Postgraduate School of Radiology’s graduated reporting policies. The Integrated Care Boards therefore understand that consultant radiologist expertise is available on a 24-hour basis either on site or through established on-call systems,. Notwithstanding this, we recognise the concern raised by the circumstances of this case regarding the timely availability and utilisation of senior radiological expertise in complex trauma cases. We will therefore ask provider organisations to review current escalation pathways and assurance processes relating to out-of-hours imaging interpretation, particularly in cases involving major trauma and complex radiological findings. The Integrated Care Boards will seek assurance through existing quality governance arrangements that:
• Escalation pathways for obtaining consultant radiologist input out of hours remain clear and well understood.
• Relevant learning identified through local provider investigations and governance processes has been considered and acted upon.
• Appropriate arrangements remain in place to support timely access to senior radiological expertise for complex cases. Having reviewed the current arrangements, the Integrated Care Boards have not identified an absence of consultant radiologist cover across Devon hospitals. However, we will continue to work with provider organisations to ensure that existing arrangements remain safe, effective and appropriately governed. We hope this response provides assurance that the concern raised has been carefully considered and that appropriate steps are being taken to review and strengthen relevant governance and escalation arrangements.
• Consultant radiologists are available at all times across the acute trusts within Devon and the wider Peninsula network.
• Overnight imaging is reported by appropriately trained radiology registrars operating within defined competency frameworks and governance arrangements.
• Escalation processes exist overnight to enable registrars and treating clinicians to seek consultant radiologist input where cases are complex, findings are uncertain, or urgent specialist advice is required.
2
• There is a formal process of next day review of overnight imaging reported by registrars aligned with the Peninsula Postgraduate School of Radiology’s graduated reporting policies. The Integrated Care Boards therefore understand that consultant radiologist expertise is available on a 24-hour basis either on site or through established on-call systems,. Notwithstanding this, we recognise the concern raised by the circumstances of this case regarding the timely availability and utilisation of senior radiological expertise in complex trauma cases. We will therefore ask provider organisations to review current escalation pathways and assurance processes relating to out-of-hours imaging interpretation, particularly in cases involving major trauma and complex radiological findings. The Integrated Care Boards will seek assurance through existing quality governance arrangements that:
• Escalation pathways for obtaining consultant radiologist input out of hours remain clear and well understood.
• Relevant learning identified through local provider investigations and governance processes has been considered and acted upon.
• Appropriate arrangements remain in place to support timely access to senior radiological expertise for complex cases. Having reviewed the current arrangements, the Integrated Care Boards have not identified an absence of consultant radiologist cover across Devon hospitals. However, we will continue to work with provider organisations to ensure that existing arrangements remain safe, effective and appropriately governed. We hope this response provides assurance that the concern raised has been carefully considered and that appropriate steps are being taken to review and strengthen relevant governance and escalation arrangements.