“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death. OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology candour panel concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death. 3. My concerns relate to – a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error; b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error; c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner; d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed; e) the potential risk of death to others in the event of a recurrence of any of the above.

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, 2024-0551

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