“The cause of the image transfer delay has not been elucidated; I am concerned that a…”
Dated 12 Feb 2014, from the coroner for Inner North London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 9 Apr 2014. A reply may have been sent and not yet published.
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.
- Report dated12 Feb 2014
- Deadline9 Apr 2014
- Published on judiciary.uk12 Feb 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University College London Hospitals NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 9 Apr 2014. A reply may have been sent and not yet published. |
| Radiology Reporting Online LLP | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 9 Apr 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) The cause of the image transfer delay has not been elucidated; I am concerned that a similar incident could recur as a consequence; (2) The lack of available data, required to investigate this issue, is also a cause for concern. This has not been addressed; (3) There is no image transfer backup process in place which could obviate against failure of the primary system; (4) The backup system in place (i.e. an oncall radiologist who can attend the hospital) appears not to have been implemented on this occasion. Again, the cause for this is unclear and I have concerns that the systems in place are not sufficiently robust; (5) The cause of the apparently erroneous scan report and steps taken to address this issue were not sufficiently clarified on the available evidence. This raises concerns that misreporting could happen again.
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, 2014-0060
- Added to Minute Book
- 8 Oct 2026
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- 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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