Georgina Swindells
12 Feb 2014 · Coroner R Brittain · London Inner (North)
The coroner's concerns
1. image transfer delay
“The cause of the image transfer delay has not been elucidated; I am concerned that a similar incident could recur as a consequence”
2. lack of data
“The lack of available data, required to investigate this issue, is also a cause for concern”
3. absence of backup process
“There is no image transfer backup process in place which could obviate against failure of the primary system”
4. backup system not implemented
“The backup system in place (i.e. an oncall radiologist who can attend the hospital) appears not to have been implemented on this occasion”
5. erroneous scan report
“The cause of the apparently erroneous scan report and steps taken to address this issue were not sufficiently clarified on the available evidence”
Responses
No published response was found on judiciary.uk.