William Harnell
22 Sept 2015 · Coroner Andrew Cox · Plymouth, Torbay and South Devon
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delay in formal reporting of original X-ray
“There was a delay of 5 days in the formal reporting of the original X-ray”
2. delay in obtaining second X-ray
“There was a further delay of 2 to 3 days in the obtaining of a second X-ray”
3. lack of knowledge of MRI guidance
“The Consultant responsible for Mr [name redacted] care did not know of Hospital guidance that an MRI should be obtained where a first X-ray is inconclusive and/or the patient complains of pain or fails to mobilise”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
This report
“There was a delay of 5 days in the formal reporting of the original X-ray;”
Identical hazardConfidence 0.90 · high
This report
“(1) There was a delay of 5 days in the formal reporting of the original X-ray;”
Later report
“A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023.”
Responses
2015-0384-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“HEE will work with key partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests.”
2015-0384-Response-by-Plymouth-Hospital-NHS-Trust.pdf ↗· Plymouth Hospitals NHS Trust
william-harnell-Response.pdf ↗· Department of Health and Social Care