Dear Assistant Coroner R Brittain,

The Royal College of Physicians (RCP) notes with concern the content of the Regulation 28 report for the prevention of future deaths related to the death of Man Yin ‘Anita’ Ng. We send our sincere condolences to the family of Mrs Ng.

This regulation 28 report is addressed to the RCP, and we have consulted neurology experts, acute medicine and general medicine experts, including our Patient Safety Committee.

The RCP notes the matters of concern raised in this report, particularly the concerns about the processes surrounding the treatment of subarachnoid haemorrhage. Many of those who present with such a clinical problem in the acute hospital setting will be picked up by emergency departments and transferred to the neurosurgeons for further management directly. In this case, Mrs Ng, who presented to a centre with a dedicated neurosurgical unit (at Coventry and Warwickshire hospital), did not have the delay which can be associated with transfer from centres without neurosurgery on site. However, the Royal College of Physicians wish to make clear that in the case where there is no neurosurgical unit, for example, a district general hospitals, pathways should be in place and do exist for transfers to be facilitated as quickly as possible for patients to receive specialist treatment. There can be delays in transfer when the neurosurgical units are full and this might be when a patient is admitted into an acute medical admissions unit to await transfer. We also note the nine hour delay from the time of presentation to the emergency department until review by a doctor and we continue to campaign on this matter as we hear from our clinicians the very concerning impact on patient outcome, as a result of unacceptable delays in emergency care.

Whilst awaiting transfer, the neurosurgeons may request further imaging such as a CT angiograph to identify aneurysms or bleeding points, although in many cases as soon as the original bleed is identified, permission will be obtained to proceed to an angiography and consent obtained as this investigation involves the use of contrast. Furthermore, occasionally, those presenting with classical signs and symptoms of a subarachnoid haemorrhage may initially have normal imaging and require a lumbar puncture which can delay diagnosis but, as soon as it is identified, patients are discussed with the neurosurgeons. Ideally, a patient should be transferred for intervention as early as possible.

There is variability in the interventional radiology services which may be available in relation to timing of intervention but also the safest time to proceed. In Mrs Ng’s case there were delays due to issues with resources and staffing. These are noted to be relatively unusual in our experience. If indeed, Mrs Ng had presented to a hospital without a dedicated neurosurgical unit, the delay may have been greater. Furthermore, we recognise that the procedure itself carries a haemorrhage risk and sadly for Mrs Ng’s family, we will not know whether, even if she had had the intervention in a timely manner, the aneurysmal sac/blood vessel walls would have been so thin and friable that she would sadly have been at risk of a re-rupture during the intervention. The risk with all intracranial/ subarachnoid haemorrhages is that they can extend.

As you mention within the Regulation 28, much of the input into the treatment of such patients falls under the purview of interventional radiologists and our physicians are mainly involved in the initial identification of a subarachnoid haemorrhage, initial referral and sometimes investigation and where necessary, if someone needs repatriation acceptance back for rehabilitation. Whilst we acknowledge your comments about interventional radiologists not having direct admitting rights, there is safety for such patients to be admitted under core specialties such as neurosurgery. The safety, for example, of those patients requiring angioplasty instead of vascular surgery in district hospitals may fall under medicine. This should provide oversight, for example, in a way the bloods can be rechecked after the intervention and pre/post hydration can be organised for those at risk of kidney failure due to the use of contrast.

We would support the NICE guidance of an MDT approach, with a discussion between interventional radiology and neurosurgery to ensure the best approach and ofcourse, patient and carer involvement.

In asking for our guidance as to who is best to manage patients with this condition, we would state that the neurosurgeons and linked MDT are best placed to manage these patients, especially due to the fact that not all centres have a dedicated neurosurgical service or neuro-interventional service and the importance of such patients being managed by these specialist teams rather than delay treatment options. This enables appropriate protocols to be in place for the safe and effective use of such services and offers the best outcomes for patients. This said, unfortunately the nature of subarachnoid haemorrhages is such that re-rupture is unpredictable, including primary rupture, and even the best neurosurgeons who manage the complex aneurysms cannot predict whether someone may rupture before intervention can be done in a safe and timely manner. Without an anaesthetist present, it would not have been safe to proceed and it may have been that if the thrombectomies, which took priority on the 20 Jan 2025, had been delayed that the patients may have suffered similar catastrophic consequences.

Indeed, the NICE guidance of the management of aneurysms causing subarachnoid haemorrhages is clear: “An interventional neuroradiologist and a neurosurgeon should discuss the options for managing the culprit aneurysm, taking into account the person's clinical condition, the characteristics of the aneurysm, and the amount and location of subarachnoid blood. They should document a proposed treatment plan based on the following options:
• endovascular coiling
• neurosurgical clipping
• no interventional procedure, with monitoring to check for clinical improvement and reassess the options for treatment.”

We would strongly support that the pathways remain unchanged and given both complications and the original ruptured aneurysm if coiling is not feasible remain under the care of the neurosurgeons.

We are happy to discuss this further with the Royal College of Surgeons and the Royal College of Radiologists if necessary. Once again, our sincere condolences to Mrs Ng’s family at this difficult time.

Dear Dr Brittain

Ref: 2025-0614

Thank you for your “Man Ng: Prevention of Future Deaths” report and for giving the RCS England the opportunity to respond.

We were saddened to read the circumstances of Man Yin ‘Anita’ Ng death and we offer our sincere condolences to her family.

Your report identified concerns in relation to the treatment of subarachnoid haemorrhage (SAH) from an intracranial aneurysm, which occurred in the perioperative care of this patient. According to the report, the main circumstances of this event relate to the lack of prompt and definitive treatment of aneurysms to prevent rebleed and, most critically, the lack of clear overall clinical responsibility of the patient’s care.

Although we have no regulatory powers, the College provides advice and guidance to those who design surgical services and to the wider surgical care team for all aspects of surgical practice. In this instance, given the specialty-specific nature of the identified issues, we consulted with our colleagues at the Society of British Neurological Surgeons (SBNS) and at the British Neurovascular Group (BNVG).

Evidence suggests1,2 that the risk of aneurysm rebleeding is highest in the first 48 hours, making early and correctly prioritised treatment critical. At a system level, increased demand on neurointerventional infrastructure, particularly from expansion of mechanical thrombectomy services, can create competition for catheter laboratory capacity, specialist staffing and anaesthesia cover. In the absence of clear national guidance on prioritisation and clinical ownership, this has led to variation in practice, fragmented responsibility, and, in some cases, to the lack of prioritisation and delays to treatment for patients with ruptured aneurysms,

1 NICE (2022). Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management.

2 AHA/ASA (2023). Guideline for the Management of Patients With Aneurysmal Subarachnoid Haemorrhage.

increasing the risk of preventable harm. In addition, patients receiving care from different specialists often lack a clear advocate, particularly in units with lower emergency volumes.

The College recognises that effective decision-making within the multi-disciplinary team (MDT) is key and that any treatment strategy in patients with aneurysmal subarachnoid haemorrhage should be decided by teams with both surgical and endovascular expertise. The specific details of how this service should be delivered by the MDT may vary and can be decided locally provided there is sufficient input by both neurosurgeons and INR colleagues, leading to safe and effective treatment.

However, we consider that neurosurgeons are best positioned to manage these patients because they are trained to manage the full spectrum of SAH complications, including pre- and post-treatment challenges, regardless of whether the definitive intervention is surgical or endovascular. Neurosurgical team working patterns are also best placed to support continuity of care, which is crucial for these complex patients.

Following this report, the College will work with the SBNS and BNVG to develop a position statement setting out recommendations for the management of the clinical care of SAH patients, and also for the provision of access to the recently published credentialling process for thrombectomy training for non-radiologists, which could allow neurosurgeons with a neurovascular interest to train in both endovascular and open surgical treatment to improve patient-centred decision-making.

We hope that this response is clear and helpful and provides you with reassurance in relation to the serious consideration we have given to these matters and the actions we shall be taking in response.

Dear Dr Brittain, RCR Response to Regulation 28: Prevention of Future Deaths report issued on 5 December 2025 in relation to the death of Man Yin ‘Anita’ Ng. I was very sorry to read about the death of Man Yin ‘Anita’ Ng and I would like to express my deepest condolences to Anita’s family. We take the matters raised in your report very seriously and I hope this reply will be helpful in outlining how we are committed to learning from them and supporting our members and Fellows to develop and maintain excellent medical care. The Royal College of Radiologists (RCR) is a charity which works with our members and Fellows to improve medical care across the specialties of Clinical Radiology and Clinical Oncology. The RCR does not commission, fund, manage, or directly deliver clinical services. Responsibility for the organisation, resourcing, and operational delivery of emergency and specialist services lies with NHS providers, commissioners, and national bodies. However, the RCR has an important role in setting professional standards, providing guidance, supporting workforce development, and advocating for system-level change where patient safety and service sustainability are at risk.

In preparing this response, we sought input from our specialty interest groups most closely aligned with this area of practice to ensure that our comments reflect the breadth of relevant expertise within the specialty. The British Society of Interventional Radiology feedback has been incorporated into the general observations set out below. We recognise and share your concerns regarding delays to investigation and treatment, variation in access to specialist neurointerventional procedures, and the challenges arising from fragmented clinical ownership across specialties. These issues reflect wider, longstanding system pressures within the NHS, including workforce shortages, constrained critical care and interventional capacity, and increasing demand for time-critical specialist radiological interventions. Your report highlights the complexity of care pathways where responsibility for admission and ongoing inpatient management may sit with one specialty, while definitive treatment is delivered by another. This model, which is common across Interventional Radiology (IR) can lead to ambiguity in clinical ownership, delays in decision-making, and difficulties in coordinating urgent care, particularly when services are under significant pressure. These

challenges are not confined to neurointerventional practice alone but are seen across multiple IR emergency and urgent care pathways, including vascular, hepatobiliary, and haemorrhage control services. As demand for minimally invasive, image-guided interventions has grown rapidly, the development of supporting infrastructure, workforce, and governance arrangements has not always kept pace. The RCR acknowledges the particular concern raised regarding the lack of admitting rights for interventional radiologists. Where interventional radiologists are responsible for delivering definitive, time-critical treatment but do not have admitting rights or direct access to inpatient beds, there can be a misalignment between procedural responsibility and overall clinical accountability. Evidence in the literature (T. Bryant, R. Ahmad, A. Diamantopoulos et al,
2023) has highlighted that admitting rights and involvement in ward-based care are important for patient safety, continuity of care, and the long-term sustainability of IR services. The RCR supports collaborative models that enable appropriate admitting rights and shared inpatient responsibility, tailored to local service configurations. We also recognise the pressures created by the rapid expansion of neurointerventional thrombectomy and aneurysm services over recent years. While these advances have delivered significant benefits for patients, their growth has often occurred in the context of limited workforce expansion and insufficient critical care, theatre, and interventional suite capacity. This has contributed to variability in service availability and resilience, particularly outside normal working hours. While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to work with partner organisations, including specialist societies and national bodies, to advocate for sustainable workforce planning, clearer clinical governance arrangements, and equitable access to specialist interventional services. We will also continue to develop and update professional guidance and standards that support timely access to care and clarify roles and responsibilities within complex, multidisciplinary pathways. I am grateful to you for bringing these matters of concern to our attention and for giving us the opportunity to respond. Once again, I express my deepest condolences to Anita’s family and loved ones.