Inquest focuses on radiologist who missed subdural hematoma

2022 11 14 15 36 6672 2022 11 14 Coroners Report Wales 400

A U.K. coroner's investigation into the case of a man who died nine days after a fall has heard that the teleradiologist failed to identify a subdural hematoma, according to a media report from the inquest held on 11 November.

John Lewis Jones, a 77-year-old retired clergyman from Colwyn Bay, North Wales, fell in his daughter's driveway on 27 June 2020. He suffered a head injury and three fractured ribs. Paramedics took him to Ysbyty Gwynedd in Bangor, and the brain CT examination was sent to Dr. David White, a consultant radiologist for Everlight Radiology.

The inquest was told that the scans showed "shallow and subtle" results, and missing it was "not unreasonable", stated the Daily Post article.

The patient was treated at Ysbyty Gwynedd in Bangor. Photo courtesy of Stock Photo.The patient was treated at Ysbyty Gwynedd in Bangor. Photo courtesy of Stock Photo.

White told the inquest that the incident had been "humbling." He admitted he may have been distracted, but White also said it was only a small bleed and other radiologists had looked at the scans and some also missed it, the Daily Post noted.

"One is disappointed, but it makes you feel a little easier knowing others may have made the same mistake," he reportedly stated, adding that new artificial intelligence (AI) software developed since Jones' death in 2020 now makes it much easier to detect such minor bleeds.

The teleradiology provider's view

Dr. Dan Rose, chair of the Global Medical Leadership Council and U.K. medical director at Everlight Radiology, also reviewed the case. The company provides support to 45 hospital groups in the U.K. and Ireland and reports 700,000 cases a year, the inquest heard.

Rose, who manages Everlight's team of radiologists and is responsible for radiologist recruitment and clinical interactions with clients, told the inquest there had been a "shallow and subtle" subdural hematoma in the scan, and this was "fed back to Dr. White" to "reflect on," the Daily Post reported.

Rose said the incident was a "good learning case" and had been shared with other radiologists. "We conducted two webinars on neurological misses and how to avoid them," he told the inquest, adding that AI would have "reduced the chance that a small bleed would not have been identified."

Kate Sutherland, the acting senior coroner for northwest Wales, said the bleed had been very small, and failing to notice it was a "not unreasonable omission," the Daily Post noted.

Sutherland gave the cause of death as subdural hematoma and chronic valvular heart disease (with Warfarin therapy). After the fall, the patient had continued on anticoagulation medication, but he sustained a further large acute subdural hematoma on 1 July 2020, after which he received palliative care and died on 6 July 2020 at midnight, she noted in her report.

In the narrative section of the report, "Natural causes contributed to by appropriate anticoagulation treatment" was the conclusion of the coroner as to the death.

The patient was reportedly fit and healthy despite having heart surgery 20 years earlier, when he was fitted with a metallic valve, according to the Daily Post.

Freelance radiologist

According to his LinkedIn page (accessed on 14 November 2022), White has worked as a full-time consultant radiologist with Everlight Radiology since April 2014. Prior to that, he was a consultant radiologist at Doncaster and Bassetlaw National Health Service (NHS) Trust for 11 years.

"I am currently working as a freelance consultant radiologist, based in Leeds, having recently returned to the U.K. from Australia, where I worked for over two years for Everlight Radiology, reporting on out of hours emergency overnight cases from the U.K.," he notes on LinkedIn.

White describes himself as an experienced general radiologist with a subspecialty interest in gastrointestinal radiology, adding that he was awarded the Rohan Williams Medal for his performance in the final Fellow of the Royal College of Radiologists examination in 2001.

Everlight was originally established in Australia as Imaging Partners Online in 2006 and entered the U.K. market in 2010 as Radiology Reporting Online -- a partnership with University College London Hospitals NHS Foundation Trust, according to the company's website.

"Having offices on opposite sides of the world was an integral part of our founders' unique vision -- to make the most of international time zones and provide 24/7 radiology reporting, while ensuring our team of radiologists only ever worked 'daylight' hours," Everlight states.

The radiologist team has grown to more than 200, all of whom are General Medical Council specialist consultants with extensive NHS experience. The company has offices in the U.K., Australia, New Zealand, and South Africa, and it also uses specialists working from home in the U.S, Canada, and the rest of Europe.

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