“The evidence before the court suggested that Mrs Dixon was not accompanied or escorted by…”

The coroner’s concerns

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1. The evidence before the court suggested that Mrs Dixon was not accompanied or escorted by a medical professional to the radiography suite. 2. Her daughter was not invited into the room when the pre-scan form was completed. 3. The consent form was filled in by the radiographer on asking questions of Mrs Dixon alone who was vulnerable, unwell, confused and hard of hearing in an unfamiliar environment without assistance. 4. The consent form was also supplemented with information from the computer records but it was not clear on the form or in evidence which information came from Mrs Dixon and which from records. 5. Part of the consent form was filled in and initialled by a person who cannot be identified by the Trust as to which member of staff it was. 6. Part of the consent form about previous contrast was left blank and although the RCA had the information before the scan it was not noted. 7. The radiographer who filled in the form had no training in communication or language difficulties and there were no other resources to aid communication and the questions were yes/no. 8. No notes were made in the radiography suite. 9. Mrs Dixon was assessed before attending the radiography suite but there was no one with clinical skills to assess her prior to the scan itself and . 10. There was no note to assist the radiographer with any vulnerabilities Mrs Dixon had (including crucially hearing and understanding difficulties and that she was not able to lie flat) 11. The way the room was set up it was difficult for the radiographer to realise that Mrs Dixon was having breathing difficulties during the scan as he was only able to see the top of her head and it was hard for him to hear over the sound of the scanner through the intercom in the scanner itself.

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, 2019-0132

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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