“6 The evidence showed that: 1”
Dated 3 Apr 2020, from the coroner for Surrey. Sent to 3 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 29 May 2020. 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 dated3 Apr 2020
- Deadline29 May 2020
- Published on judiciary.uk20 Apr 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal College Emergency Medicine | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 May 2020. A reply may have been sent and not yet published. |
| General Medical Council | Response publishedPublished on judiciary.uk in April 2020. |
| College and Society of Radiographers | Response publishedPublished on judiciary.uk in April 2020. |
The coroner’s concerns
– 6 The evidence showed that: 1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken. 2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.
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, 2020-0089
- 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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