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Gillian Baumgardt

28 Feb 2024 · Coroner Simon Fox · Avon
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The coroner's concerns

  1. 1. wrong site surgery in elderly patients with dementia

    “Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture”

  2. 2. absence of pre-exposure marker in x-ray field

    “There is no system requiring radiographers to ensure that pre-exposure markers are present in the x- ray field in all such patients”

  3. 3. lack of investigation of image inconsistency

    “There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients”

Responses

2024-0112-Response-from-North-Bristol-NHS-Trust.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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