Recurance · prevention of future deaths reports
Pre-inquest brief
Delay in reporting original x-ray findings to clinicians
The earlier warning
William Harnell · 22 Sept 2015 · Andrew Cox, Plymouth, Torbay and South Devon
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
judiciary.uk/prevention-of-future-death-reports/william-harnell
What was promised
Stated action 1 · response to William Harnell (22 Sept 2015) · stated timescale: none stated
“HEE will work with key partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests.”
judiciary.uk/…/2015-0384-Response-by-Department-of-Health.pdf
What recurred
- 16 Oct 2023 · Claire Twinn · Graeme Irvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · William Harnell · 22 Sept 2015
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
Later · Claire Twinn · 16 Oct 2023
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”
What happened next
No web check of the stated actions has been published for this chain.