Life changing scans are left on a clinician’s desk for 6 days, resulting in death
Posted on May 31st 2022
An inquest has been held looking into the shocking death of Trevor Reynolds after a CT scan found a deadly blood clot but the results were left unread on a Consultant’s desk for 6 days.
Mr Reynolds was a 79 year old retired HGV driver with cancer of the oesophagus. He had been receiving treatment at Ysbyty Glan Clywd. On 3rd May 2021 he was sent for a CT scan, which was reviewed by a Radiologist, three days later. The radiology report stated that he had a blood clot which required urgent care.
The results of the scan were left, unread, on a Consultant’s desk who was on annual leave until 12th May. Whilst waiting to receive the results of the scan from the hospital, Mr Reynolds’ health deteriorated and he began having difficulty breathing. His GP visited him at home and sent him immediately to hospital.
Unfortunately, it was too late to treat the blood clot and Mr Reynolds sadly passed away on 15th May 2021.
The Defendant Trust have admitted that had the results been passed onto a clinician urgently, Mr Reynolds’s chances of survival would have been higher.
The hospital has since made major changes as to how unexpected results and findings are passed onto alternative senior clinicians if a Consultant is not available, but these changes still took 8 months to implement.
An audit is yet to be completed following these changes to confirm their effectiveness, but the Coroner has raised a ‘Prevention of Future Deaths Report’ against the Trust, in the hope of preventing further tragedy. A Prevention of Future Deaths report is a report which the Coroner puts together with actions they believe should be taken to prevent future deaths.
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