The coroner highlighted concerns about the sharing of radiology imaging between NHS hospitals and external radiology companies.
A woman died of severe internal bleeding at Pembury Tunbridge Wells Hospital in the Maidstone and Tunbridge Wells NHS Trust after her aortic root aneurysm was missed by doctors.
The woman attended A&E in October 2023 complaining of severe chest pain but was discharged home after three days.
HM Coroner Catherine Wood at North West Kent Coroner’s Court found that there was a missed opportunity to diagnose and treat the woman, who had a history of vasculitis – an inflammation of the blood vessels – and was being monitored for an aneurysm at the aortic root.
When she was brought in to A&E, an urgent CT scan of her aorta was requested, but the referral for the scan did not mention her aortic root aneurysm.
The inquest heard that a scan was undertaken, and the images were transferred to an external radiology company, Telemedicine Clinic, Europe’s largest teleradiology reporting provider. The reporting radiologist at the external company did not have access to previous imaging of the woman’s heart and was not made aware of the aortic root aneurysm.
The scan was reported as showing no signs of concern.
“This inquest has been incredibly difficult for all those involved. The process has facilitated a thorough investigation into Lucy’s death and found that Lucy would likely still be alive had she received different care,” said Leigh Day solicitor Ceilidh Robertson.
Sharing of radiology imaging
The woman was kept in hospital and further investigations were carried out to try to identify an alternative cause for her symptoms. It was thought that she was suffering from inflammation, and she was prescribed steroids and anti-inflammatory medication and was discharged.
Three days later, she collapsed at home and died that morning.
The coroner found that not all of the information that should have been on the request form for the woman’s CT scan was provided and that this was compounded by the fact that the radiologist analysing the imaging did not have access to previous scans.
The coroner also found that the radiologist should have indicated in her report that there were problems with the imaging and that it was not possible to rule out an acute problem with her aorta.
The coroner added that if further imaging had been undertaken the problem with her aorta would have been identified, and she would have been transferred for emergency surgery and, on the balance of probabilities, would have survived.
The coroner will be writing a Prevention of Future Deaths report to the Department of Health highlighting her concerns about the sharing of radiology imaging between NHS hospitals and external radiology companies.
