“Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from…”
Dated 9 Oct 2025, from the coroner for East London. 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 4 Dec 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 dated9 Oct 2025
- Deadline4 Dec 2025
- Published on judiciary.uk14 Oct 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS Trust | Response publishedPublished on judiciary.uk in October 2025. |
The coroner’s concerns
Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists. In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported. In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The latter finding was of direct clinical interest. None of these findings were reported. On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported. The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place. In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
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, 2025-0499
- Added to Minute Book
- 8 Oct 2026
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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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