“An independent radiology expert confirmed that the left pneumothorax was clearly apparent…”
Dated 15 Jun 2017, 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 10 Aug 2017.
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 dated15 Jun 2017
- Deadline10 Aug 2017
- Published on judiciary.uk9 Aug 2017
- 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 August 2017. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax. 2. The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure. Had she checked the system she would have seen the x-ray taken at 12:37 showing the large left pneumothorax. She would also have seen the outstanding request for a chest xray. Both the independent radiology expert and the Trust radiology witness (Dr G), confirmed that recent radiology should be checked by the radiologist prior to performing this procedure. 3. The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus. The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage. 4. There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him. 5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing.
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, 2017-0190
- 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
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