Lydia Corah
11 May 2015 · Coroner Stephanie Haskey · Nottinghamshire
The coroner's concerns
1. unnecessary x ray on wrong patient
“there was an error, or series of errors, which led to Mrs [name redacted] undergoing an x ray which had been indicated for a different patient, so causing her to experience delay in assessment and treatment and to receive an unnecessary dose of radiation”
Responses
2015-0181-Response.pdf ↗· Nottingham University Hospitals NHS Trust
Stated action
“A Root Cause Analysis is routinely employed in all cases of incorrect referrals for medical imaging. The RCA will generate an action plan which is managed by the responsible Directorate. The RCA for this patient is attached (appendix 1). It is difficult to be certain of the cause of the patient identification error. The experienced (Consultant) investigator concludes that the most likely cause to be a mistake whilst using the electronic requesting system (Notis). It is possible to open multiple”