“are: – The evidence revealed that when Radiologists are asked to interpret a scan, the…”
Dated 26 Aug 2025, from the coroner for Sunderland. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Oct 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated26 Aug 2025
- Deadline21 Oct 2025
- Published on judiciary.uk2 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Tyneside and Sunderland NHS Foundation Trust | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
are: – The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted – not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed. I shall be glad to be told of any learning arising from this death and timescales and results of your review.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0439
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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