Ronald Lowe
3 Apr 2019 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. radiographers not seeing CT SOPs
“Investigations have identified that there is no evidence that the radiographer, , who undertook scan on the 20th September 2018 had seen the standard operating procedures for CT applicable in September 2018. 2. It was evidence that he had not seen these SOPs”
2. lack of robust system for ensuring radiographers see SOPs
“I am concerned that it had previously gone unnoticed that had not signed a copy of the SOPs for CT indicating that there is not a robust system for ensuring radiographers have seen all standard operating procedures relevant to their practice. Consequently there is a risk that radiographers are practicing with an incorrect understanding of their duties and obligations which could endanger life.”
Responses
2019-0113-Response-by-University-Hospitals-Birmingham-NHS-Trust.pdf ↗· University Hospitals Birmingham NHS Foundation Trust
Stated action
“The practice in place at the time was that when a new procedure was launched, a global email was sent to all radiographers attaching the document and asking that staff sign and return a form to the CT lead. This form was reviewed by the CT lead and retained by them in a central folder within the CT department. Where staff did not return their forms, this was followed up by the CT lead with the individual radiographer to ensure that every radiographer is aware of any new procedure/document”