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recurance

Raisa Iordan

31 Mar 2026 · Coroner Charlotte Keighley · West Yorkshire Western

The coroner's concerns

  1. 1. clinical assessment limited and poor quality

    “Concerns were raised by a Junior Doctor in respect of [the deceased]'s presenting symptoms, which were ignored by the more Senior Doctor in charge, whose assessment of [the deceased] was limited and of poor quality. The more Senior Doctor formed a view that [the deceased] was experiencing febrile convulsions and they were unwilling to consider the views, observations or concerns raised by not only the Junior Doctor but by other clinicians who had been caring for [the deceased] during the course of her admission.”
  2. 2. misinterpretation of paediatric imaging

    “Since September 2021, the standard practice across the Mid Yorkshire Teaching NHS Trust has been that the interpretation of out of hours radiology is provided by an external agency, Telemedicine Clinic Limited ("TMC"). The company provides radiology reporting services to a large number of hospitals, providing, amongst other things, acute on call radiology reporting services. Although TMC has a number of radiologists available from a variety of subspecialties to provide reports, their expertise are”
  3. 3. delayed critical imaging

    “There were delays in obtaining a scan for [the deceased] as there was only one on call anaesthetist at Dewsbury and one on call radiographer. The scan was required prior to [the deceased] being transferred as the treating clinicians needed to ensure that not only was it safe for [the deceased] to be transferred but also that she was being transferred to a Hospital that was able to provide appropriate care, there being no paediatric intensive care unit at Pinderfields Hospital.”
  4. 4. intubation delay

    “There were delays in [the deceased] being intubated as there was no support for the on call anaesthetist, with no Operating Department Practitioner or other trained member of staff to help manage a critically ill paediatric patient.”

Responses

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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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Raisa Iordan · Recurance