“During the Inquest evidence was heard that: i, There was no on call rota for a GI…”

The coroner’s concerns

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1. During the Inquest evidence was heard that: i, There was no on call rota for a GI Radiologist to perform a percutaneous cholecystostomy out of hours and particularly over a weekend. The Hospital Trust indicated that a risk had been identified in relation to the unavailability of GI Radiologists out of hours and the Hospital that managed the risk by allowing the GI Radiologist to be contacted out of hours but the Trust accepted that there was no provision for the Radiologist to be available out of hours. ji, The Consultant Surgeon gave evidence at the Inquest that availability of a GI Radiologist to perform a percutaneous cholecystostomy was critical to the management of a patient and he raised concerns that there would be a risk to life if a percutaneous cholecystostomy could not be performed out of hours, either overnight or over a weekend. I accepted evidence at the Inquest that the Salford Royal NHS Foundation Trust were considering actions to make GI Radiologist available out of hours and to establish a system for any Radiologist to contact a GI Radiologist our of hours for procedures to be conducted out of hours. However there was no confirmation that an out of hours on call rota was being considered for GI Radiologists either within the Salford Royal NHS Foundation Trust or for a rota to relate to a wider area covering several other hospitals on the basis that an available Radiologist could travel to different hospitals to carry out a necessary procedure out of hours. Evidence was given at the Inquest that the unavailability of GI Radiologists was not limited to Salford but was a national problem in that there were very few out of hours on call rotas for GI Radiologists in hospitals in the United Kingdom. Tt was accepted that a perforated gall bladder was a recognised condition, which occurred on a regular basis as an emergency presentation to hospital. In some cases surgical intervention would not be appropriate and an alternative treatment plan would involve the insertion of a percutaneous cholecystostomy drain or a drain to be inserted outside the gall bladder, both of which would require insertion by a GI Radiologist. The evidence raised concerns that there is a risk of future deaths will occur unless action is taken to review the above issues. 2. T request you to consider the above concerns and to carry out a review with regards to the fact The availability of GI Radiologists out of hours to perform procedures crucial to the management of the patient, including the provision of out of hour's rotas either within a single Hospital Trust or a rota as between hospitals in a group of Hospital Trusts. ‘The provision of an out of hour's rota as referred to in 2.i, above within Salford Royal NHS Foundation Trust The provision of procedures and protocols in relation to the availability of GI Radiologists out of hours and a definitive line of communication whether it be as between Radiologists or by diinical Consultant direct to GI Radiologists to discuss and arrange a procedure out of hours. The training of health professionals in relation to the availability of GI Radiologists out of hours including training in relation to the procedures and protocols established in support of out of hours availability. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.

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, 2015-0281

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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