Matthew Goldsmith
PFD Report
All Responded
Ref: 2025-0499
All 1 response received
· Deadline: 4 Dec 2025
Coroner's Concerns (AI summary)
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
View full coroner's concerns
Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists.
In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The latter finding was of direct clinical interest. None of these findings were reported.
On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The latter finding was of direct clinical interest. None of these findings were reported.
On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
Responses
Action Taken
Barking, Havering and Redbridge University Hospitals NHS Trust has implemented an action plan to address missed radiological findings, including mandatory training for radiologists, improved peer review processes, and use of discrepancy data to drive system improvement. (AI summary)
Barking, Havering and Redbridge University Hospitals NHS Trust has implemented an action plan to address missed radiological findings, including mandatory training for radiologists, improved peer review processes, and use of discrepancy data to drive system improvement. (AI summary)
View full response
Dear Ms Persaud,
Thank you for your Regulation 28 Report issued on 9 October 2025 in relation to the death of Mr Matthew Goldsmith. Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) has carefully considered the matters of concern raised by the Coroner, acknowledges these findings, and has implemented an action plan to reduce the risk of a recurrence of missed radiological findings. The Trust also extends its sincere condolences to Mr Goldsmith’s family.
The matters of concern identified in the Regulation 28 Report and the Trust’s responses are set out below.
Missed Abnormal Findings on CT Scans and the Coroner noted the absence of a formal peer review system for Radiology reporting, as required by the Royal College of Radiologists RCR).
The full concerns were:
1. Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists.
2. In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
3. In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The PRIVATE AND CONFIDENTIAL Ms Nadia Persaud HM Area Coroner Walthamstow Coroner’s Court Queens Road London Date: 20 November 2025 Legal Services Queen’s Hospital Rom Valley Way, Romford, RM7 0AG
latter finding was of direct clinical interest. None of these findings were reported.
4. On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
5. The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
6. In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
Trust Response
Following receipt of the Regulation 28 Report on 9 October 2025, a multidisciplinary review meeting was convened on 15 October 2025. This meeting included senior clinical and managerial representatives from Radiology, Nursing, Governance, Legal Services, and the Medical Directorate to review the findings and develop a comprehensive action plan.
The Trust recognises that the missed findings represent a serious quality concern and accepts the Coroner’s recommendations in full. The following actions are being implemented:
The Radiology senior team are in the process of outlining a Radiology Governance Framework (project plan) by aligning workstreams, responsible leads and measuring key outputs by each of the governance domains and fundamentally ensuring that this links back to the SEIPS plan (Systems Engineering Initiative for Patient Safety) methodology. This is a working plan which in the coming months will be discussed with clinical and non-clinical staff for oversight and approval. Within this plan there are essential domains which responds to the coroner’s concerns and will be standalone items to ensure that they are progressed without delay and detailed below including an action plan. With the framework there will be enhanced oversight and assurance through the Corporate Quality & Safety Team, Radiology Governance Forum, and Legal Services.
• Introduction of a SEIPS-based project to identify and address human and system factors contributing to reporting discrepancies.
• Development and implementation of a peer review process for Radiology in alignment with RCR guidance, ensuring systematic case review and feedback mechanisms.
Action Plan
Action Area Specific Actions Outputs Timeline/lead
1.A project plan to be developed to outline implementation of a rapid review of discrepancies using SEIPS methodology
2. The review of the wider Radiology Governance framework and the establishment of workstreams Implement dual- track PSIRF (SEIPS + Systems Thinking) for discrepancy learning.
Action plan developed for workstreams ≥90% discrepancy reviews completed monthly using SEIPS process.
Addresses external factors learning from diagnostic errors and reduces recurrence risk whilst also maintaining principles of Radiology events and Learning meeting (REALM)
12 December 2025
– Feb 2026
Radiology Professional Lead, Consultant Radiologist and Service Development Manager Clinical & Governance Lead consultants in Radiology to introduce Peer Review Process and required assurances Introduce a peer review process within Radiology to further identify, discuss, and learn from interpretation discrepancies in addition to REALM.
Radiology will conduct 3% each month rising to 5% from June 2026 Monthly peer reviews completed; learning outcomes presented in governance meetings; summary dashboard produced showing learning and outcomes and themes identified.
Supports quality improvement, PSIRF learning culture and professional development 12 December 2025
Radiology Governance Lead And Radiology Clinical Lead
The specific actions arising from Patient Safety Incident Investigation (PSII) have been included for assurance:
1. A grand round teaching session will be delivered on 11 December 2025 by the Surgical Clinical Group around acute and chronic presentation of mesenteric arterial occlusion. The Grand round is a regular learning session led by the Director of Medical Education to review incidents where learning has been established. At this grand round colleagues from the upper Gastrointestinal and Vascular teams were present.
2. The case was presented at the BHRUT Patient Safety Summit (PSS) on 23 July 2025 for Trust wide learning. The PSS is a monthly Trust wide open forum for staff to attend and learn about incidents that have significant learning outcomes. This embeds shared learning for all and is also available on the intranet for staff that are unable to join.
3. BHRUT has implemented Electronic Patient Record (EPR) system from week commencing 08 November 2025 which will enable Radiologists and referring clinician’s to record real-time decisions and clinical advice directly into the patients record.
Plain Film Peer Review Within Radiology, the plain film x-ray specialty has already commenced peer reviews which has been in place for over 12 months and from July 2025, the specialty has managed to peer review 5% of cases and is being led by the Radiology Specialty lead. A Standard operating procedure was created and will be replicated to the other modality/specialty areas. A shared governance file stores all reviewed cases.
Teleradiology Governance
BHRUT use Everlight outside of normal working hours to ensure 24 hour imaging cover.
Should there be a discrepancy the imaging/report is reviewed at REALM, letters to Radiologists are produced where needed, and uploaded to Everlight’s Governance Portal for action. Everlight then conducts a peer review and produces a governance report (confidential).Everlight operates a structured clinical governance system, which includes:
• A blame-free learning culture with rigorous peer review.
• 2–10% of all Radiology reports subject to structured internal peer review.
• Review of all Level 1 and 2 discrepancies by the Medical Leadership Council (MLC)
• Personal reflection learning forms for Radiologists involved in significant discrepancies.
• Regular Clinical Governance Everlearning webinars are held, open to all Everlight Radiologists, where cases identified via the peer review process are shared and learning points reinforced. These webinars are also recorded and made available offline for review. Everlight Radiologists are required to attend or view the majority of these meetings
• Learning is also shared via monthly Everlearning Bulletins which contains details of interesting cases and learning points, and regular email newsletter to all Radiologists
• Use of discrepancy data to identify trends and drive system improvement. These processes are widely recognised as more rigorous than standard NHS governance models and BHRUT Radiology aims to mirror best practice for peer reviews and discrepancies to Everlight’s process.
The Trust takes the Coroner’s findings extremely seriously and is committed to ensuring that the learning from this case translates into measurable and sustained improvements in radiological practice.
We thank the Coroner for highlighting these critical issues. The Trust is fully committed to completing all actions within the specified timelines, with progress rigorously monitored through established governance processes. We will ensure that these measures are fully implemented and embedded into routine practice, driving sustained improvements in patient safety and the quality of radiological care.
I would be happy to meet with you to discuss this response if that would be helpful.
Thank you for your Regulation 28 Report issued on 9 October 2025 in relation to the death of Mr Matthew Goldsmith. Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) has carefully considered the matters of concern raised by the Coroner, acknowledges these findings, and has implemented an action plan to reduce the risk of a recurrence of missed radiological findings. The Trust also extends its sincere condolences to Mr Goldsmith’s family.
The matters of concern identified in the Regulation 28 Report and the Trust’s responses are set out below.
Missed Abnormal Findings on CT Scans and the Coroner noted the absence of a formal peer review system for Radiology reporting, as required by the Royal College of Radiologists RCR).
The full concerns were:
1. Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists.
2. In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
3. In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The PRIVATE AND CONFIDENTIAL Ms Nadia Persaud HM Area Coroner Walthamstow Coroner’s Court Queens Road London Date: 20 November 2025 Legal Services Queen’s Hospital Rom Valley Way, Romford, RM7 0AG
latter finding was of direct clinical interest. None of these findings were reported.
4. On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
5. The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
6. In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
Trust Response
Following receipt of the Regulation 28 Report on 9 October 2025, a multidisciplinary review meeting was convened on 15 October 2025. This meeting included senior clinical and managerial representatives from Radiology, Nursing, Governance, Legal Services, and the Medical Directorate to review the findings and develop a comprehensive action plan.
The Trust recognises that the missed findings represent a serious quality concern and accepts the Coroner’s recommendations in full. The following actions are being implemented:
The Radiology senior team are in the process of outlining a Radiology Governance Framework (project plan) by aligning workstreams, responsible leads and measuring key outputs by each of the governance domains and fundamentally ensuring that this links back to the SEIPS plan (Systems Engineering Initiative for Patient Safety) methodology. This is a working plan which in the coming months will be discussed with clinical and non-clinical staff for oversight and approval. Within this plan there are essential domains which responds to the coroner’s concerns and will be standalone items to ensure that they are progressed without delay and detailed below including an action plan. With the framework there will be enhanced oversight and assurance through the Corporate Quality & Safety Team, Radiology Governance Forum, and Legal Services.
• Introduction of a SEIPS-based project to identify and address human and system factors contributing to reporting discrepancies.
• Development and implementation of a peer review process for Radiology in alignment with RCR guidance, ensuring systematic case review and feedback mechanisms.
Action Plan
Action Area Specific Actions Outputs Timeline/lead
1.A project plan to be developed to outline implementation of a rapid review of discrepancies using SEIPS methodology
2. The review of the wider Radiology Governance framework and the establishment of workstreams Implement dual- track PSIRF (SEIPS + Systems Thinking) for discrepancy learning.
Action plan developed for workstreams ≥90% discrepancy reviews completed monthly using SEIPS process.
Addresses external factors learning from diagnostic errors and reduces recurrence risk whilst also maintaining principles of Radiology events and Learning meeting (REALM)
12 December 2025
– Feb 2026
Radiology Professional Lead, Consultant Radiologist and Service Development Manager Clinical & Governance Lead consultants in Radiology to introduce Peer Review Process and required assurances Introduce a peer review process within Radiology to further identify, discuss, and learn from interpretation discrepancies in addition to REALM.
Radiology will conduct 3% each month rising to 5% from June 2026 Monthly peer reviews completed; learning outcomes presented in governance meetings; summary dashboard produced showing learning and outcomes and themes identified.
Supports quality improvement, PSIRF learning culture and professional development 12 December 2025
Radiology Governance Lead And Radiology Clinical Lead
The specific actions arising from Patient Safety Incident Investigation (PSII) have been included for assurance:
1. A grand round teaching session will be delivered on 11 December 2025 by the Surgical Clinical Group around acute and chronic presentation of mesenteric arterial occlusion. The Grand round is a regular learning session led by the Director of Medical Education to review incidents where learning has been established. At this grand round colleagues from the upper Gastrointestinal and Vascular teams were present.
2. The case was presented at the BHRUT Patient Safety Summit (PSS) on 23 July 2025 for Trust wide learning. The PSS is a monthly Trust wide open forum for staff to attend and learn about incidents that have significant learning outcomes. This embeds shared learning for all and is also available on the intranet for staff that are unable to join.
3. BHRUT has implemented Electronic Patient Record (EPR) system from week commencing 08 November 2025 which will enable Radiologists and referring clinician’s to record real-time decisions and clinical advice directly into the patients record.
Plain Film Peer Review Within Radiology, the plain film x-ray specialty has already commenced peer reviews which has been in place for over 12 months and from July 2025, the specialty has managed to peer review 5% of cases and is being led by the Radiology Specialty lead. A Standard operating procedure was created and will be replicated to the other modality/specialty areas. A shared governance file stores all reviewed cases.
Teleradiology Governance
BHRUT use Everlight outside of normal working hours to ensure 24 hour imaging cover.
Should there be a discrepancy the imaging/report is reviewed at REALM, letters to Radiologists are produced where needed, and uploaded to Everlight’s Governance Portal for action. Everlight then conducts a peer review and produces a governance report (confidential).Everlight operates a structured clinical governance system, which includes:
• A blame-free learning culture with rigorous peer review.
• 2–10% of all Radiology reports subject to structured internal peer review.
• Review of all Level 1 and 2 discrepancies by the Medical Leadership Council (MLC)
• Personal reflection learning forms for Radiologists involved in significant discrepancies.
• Regular Clinical Governance Everlearning webinars are held, open to all Everlight Radiologists, where cases identified via the peer review process are shared and learning points reinforced. These webinars are also recorded and made available offline for review. Everlight Radiologists are required to attend or view the majority of these meetings
• Learning is also shared via monthly Everlearning Bulletins which contains details of interesting cases and learning points, and regular email newsletter to all Radiologists
• Use of discrepancy data to identify trends and drive system improvement. These processes are widely recognised as more rigorous than standard NHS governance models and BHRUT Radiology aims to mirror best practice for peer reviews and discrepancies to Everlight’s process.
The Trust takes the Coroner’s findings extremely seriously and is committed to ensuring that the learning from this case translates into measurable and sustained improvements in radiological practice.
We thank the Coroner for highlighting these critical issues. The Trust is fully committed to completing all actions within the specified timelines, with progress rigorously monitored through established governance processes. We will ensure that these measures are fully implemented and embedded into routine practice, driving sustained improvements in patient safety and the quality of radiological care.
I would be happy to meet with you to discuss this response if that would be helpful.
Sent To
- Barking, Havering and Redbridge University Hospitals NHS Trust
Response Status
Linked responses
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56-Day Deadline
4 Dec 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 8 November 2024 I commenced an investigation into the death of Matthew Goldsmith (44 years old at the time of his death). The investigation concluded at the end of the inquest on the 7 October 2025. The conclusion of the inquest was a narrative conclusion: Mr Goldsmith died as a result of an occluded superior mesenteric artery. The stenosed artery was apparent, but missed, on the reporting of a CT scan in April 2024. Identification of this pathology in April 2024 would have prevented his death.
Circumstances of the Death
Matthew Goldsmith had a past medical history of epilepsy and a smoking history from the age of 16. From March 2023, he suffered from intermittent abdominal pain, loose stools and significant weight loss. In March 2024 he was referred to the colorectal team by his general practitioner. Investigations were undertaken, including a CT scan of the chest, abdomen and pelvis. The CT scan was reported as showing no significant abnormality. Malignancy was excluded. The CT scan did not report a severe stenosis of the superior mesenteric artery which could be seen on the lower section of the chest CT scan. These findings were relevant to his clinical presentation. Had this finding been identified and reported, this would have indicated referral to the vascular surgical team. Had such a referral been made, there was an opportunity of providing care to Mr. Goldsmith which would have prevented his death. On the 7 October 2024, Mr. Goldsmith presented to the emergency department with increasing abdominal pain, continuing loose stool and substantial weight loss. Investigations were requested, including a CT scan of the abdomen. The CT scan of the abdomen reported occlusion of the infrarenal aorta and thinning of the small bowel wall, which could reflect chronic ischaemia. The reporting radiologist did not identify a complete occlusion of the superior mesenteric artery. If this finding had been identified, there would have been an opportunity to refer Mr. Goldsmith to the vascular surgical team. The evidence does not reveal that referral to the vascular surgical team at this time would have prevented his death. A colonoscopy revealed a chronic fibrotic ulcer, which was believed by the treating team (physician and gastroenterologist) to have caused Mr. Goldsmith's symptoms. Mr. Goldsmith was discharged from hospital on 16 October 2024. Sadly, on the 28 October 2024, Mr. Goldsmith returned to the emergency department severely unwell, with severe abdominal pain. A working diagnosis of shock due to an acute on chronic bowel ischaemia, due to aortic occlusion was made. Despite all efforts at this time, Mr. Goldsmith did not recover. He passed away at Queen's Hospital on the 29 October 2024. He died as a result of an occluded superior mesenteric artery causing bowel ischaemia and bowel perforation
Copies Sent To
who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 October 2025
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.