“The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in…”

The coroner’s concerns

– 1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness for purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging.

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, 2022-0213

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