“(brief summary of matters of concern) In the course of the Inquest I heard evidence which…”

The coroner’s concerns

(brief summary of matters of concern) In the course of the Inquest I heard evidence which raised the following concerns:1) Concerns were raised by a Junior Doctor in respect of Raisa's presenting symptoms, which were ignored by the more Senior Doctor in charge, whose assessment of Raisa was limited and of poor quality. The more Senior Doctor formed a view that Raisa was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for Raisa during the course of her admission. 2) Since September 2021, the standard practice across the Mid Yorkshire Teaching NHS Trust has been that the interpretation of out of hours radiology is provided by an external agency, Telemedicine Clinic Limited ("TMC"). The company provides radiology reporting services to a large number of hospitals, providing, amongst other things, acute on call radiology reporting services. Although TMC has a number of radiologists available from a variety of subspecialties to provide reports, their expertise are limited to that of adult radiology, rather than paediatric radiology. At the time the scan was undertaken, the radiographer raised concerns that the imaging appeared abnormal and contacted TMC to ensure that no further imaging was required and in the course of that conversation, concerns were raised in respect of raised intracranial pressure. When the images were reported by TMC, it was said that there was no convincing evidence of acute intracranial pathology, but when Raisa's imaging was reviewed at Sheffield Children's Hospital, it was noted that there was obvious brain herniation which had not been identified by the general radiologist at TMC. 3) There were delays in obtaining a scan for Raisa as there was only one on call anaesthetist at Dewsbury and one on call radiographer. The scan was required prior to Raisa being transferred as the treating clinicians needed to ensure that not only was it safe for Raisa to be transferred but also that she was being transferred to a Hospital that was able to provide appropriate care, there being no paediatric intensive care unit at Pinderfields Hospital. 4) There were delays in Raisa being intubated as there was no support for the on call anaesthetist, with no Operating Department Practitioner or other trained member of staff to help manage a critically ill paediatric patient.

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, 2026-0190

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