A U.K. coroner's report into the death of a patient last year suggests that future deaths can be prevented by addressing four key issues in the radiology department.
In a report dated 22 December 2025, Adrian Farrow, assistant coroner for Greater Manchester South, noted that the death of Winifred Wardle, an 88-year-old who was admitted to Tameside General Hospital in Ashton-under-Lyne, occurred after dark brown vomiting.
A CT scan was deemed to be necessary by the treating doctors, but the scan was delayed for four days, according to the report. The patient died on 9 January 2025.
An inquest following the death revealed that she died of respiratory failure, aspiration pneumonia, incarcerated hernia, ischemic heart disease, and frailty. Complications of a lung infection caused by aspiration immediately prior to necessary hernia repair surgery also contributed, the coroner noted.
However, evidence at the inquest was that earlier surgery would have been beneficial, but that surgery could not be undertaken before the CT scan definitively diagnosed the problem: an incarcerated hernia.
"In Mrs. Wardle’s case, the radiologist declined the request in favour of an abdominal x-ray to investigate for constipation," Farrow explained. The x-ray was undertaken on 14 January and was inconclusive, by which time, blood tests revealed raised inflammatory markers and worsening condition that were indicative of the as yet undiagnosed incarcerated hernia.
"It was not possible to say whether the delay in diagnosis was causative of Mrs. Wardle’s death," he noted, warning that "future deaths could occur unless action is taken."
The coroner's report highlighted four matters concerning the radiology department that were relevant in this case:
- An absence within the Tameside General Hospital of a clear protocol for a multidisciplinary approach to CT scan requests.
- The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis.
- The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at the ward level, even by consultants (senior doctors).
- The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
"The evidence was that there was uncertainty about the communications between the ward and the radiology department as to the discussions during the period between the first request for the scan and the agreement by the radiology department to carry it out," Farrow wrote. The scan undertaken on 17 January revealed the incarcerated hernia.
Farrow has requested an action plan and response by 16 February 2026.
