Dorothy Webb
16 Aug 2017 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. missed assessment of scan leading to missed diagnosis
“Evidence emerged during the inquest that there was a missed opportunity and failure by the Radiologist to assess the scan which would have resulted in further investigation of the”
2. failure to note fracture on x-ray
“There was also a failure to note a fracture from the x-ray during the admission in February 2017 and consequently the patient and family were unaware of its existence until the re-admission in April 2017”