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recurance

Violet Nelson

7 Dec 2017 · Coroner Peter Bedford · Berkshire

The coroner's concerns

  1. 1. lack of consultant radiologist oversight of ultrasound reports

    “If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant [name redacted], it is likely that referral of Mrs [name redacted] to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP”

Responses

2017-0356-Response-by-RCGP.pdf ↗· Royal College of General Practitioners

Stated action

“The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs.”

2017-0356-Response-by-SoR.pdf ↗· Royal College of General Practitioners

Stated action

“We will review the SCoR and BMUS guidelines (2017), specifically to include guidance on referral of suspected supra-renal abdominal aortic aneurysms for thoracic CT, review by a radiologist or a vascular surgeon.”
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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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Violet Nelson · Recurance