Akash Bhudia
PFD Report
All Responded
Ref: 2023-0164
All 1 response received
· Deadline: 14 Jul 2023
Coroner's Concerns (AI summary)
Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.
View full coroner's concerns
The Xray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up Xray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner.
The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer.
The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer.
Responses
Action Taken
Medica have edited their Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers, and this has been circulated to all reporters. They will also work with clients to enact the Academy of Royal College/RCR Alerts guidelines 2022. (AI summary)
Medica have edited their Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers, and this has been circulated to all reporters. They will also work with clients to enact the Academy of Royal College/RCR Alerts guidelines 2022. (AI summary)
View full response
Dear Miss Persaud
Thank you for your email dated 19/5/23 and the enclosed Regulation 28 Report (attached as reference).
Since the inquest Medica have edited the Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers. The alert and the report should advise the referrer that a change of treatment may be required.
This new policy has been circulated to all reporters and a communication from me has highlighted the findings of the inquest to all reporters.
Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.
I would like to respond to the following areas of the Regulation 28 Report:
Section 5. The CXR was reported in a way that raised the possibility of atypical pneumonia. At the time of reporting the CXR the reporter had no knowledge of the additional information available in the court, there were no red flag symptoms for TB given in the clinical request and the CXR findings could have been caused by a number of pathogens including TB and COVID amongst others including fungi and less common bacteria. Therefore, the Xray was reported in what I would consider a standard way. Section 5. At the time of the CXR in question, I would consider Akash to have been under the care of his GP. My comment regarding a clinical team was meant to indicate primary, secondary and tertiary care if there is an element of active management/follow up. IRMER 2017 regulations place onus on the referrer to read and act appropriately on imaging reports of studies they have initiated. Section 5. There is an agreed Medica Alerts policy and an agreed Medica/Barts Alerts policy in place now and at the time of the reporting of the CXR. This did not overtly specify a need to alert TB.
Thank you for your email dated 19/5/23 and the enclosed Regulation 28 Report (attached as reference).
Since the inquest Medica have edited the Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers. The alert and the report should advise the referrer that a change of treatment may be required.
This new policy has been circulated to all reporters and a communication from me has highlighted the findings of the inquest to all reporters.
Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.
I would like to respond to the following areas of the Regulation 28 Report:
Section 5. The CXR was reported in a way that raised the possibility of atypical pneumonia. At the time of reporting the CXR the reporter had no knowledge of the additional information available in the court, there were no red flag symptoms for TB given in the clinical request and the CXR findings could have been caused by a number of pathogens including TB and COVID amongst others including fungi and less common bacteria. Therefore, the Xray was reported in what I would consider a standard way. Section 5. At the time of the CXR in question, I would consider Akash to have been under the care of his GP. My comment regarding a clinical team was meant to indicate primary, secondary and tertiary care if there is an element of active management/follow up. IRMER 2017 regulations place onus on the referrer to read and act appropriately on imaging reports of studies they have initiated. Section 5. There is an agreed Medica Alerts policy and an agreed Medica/Barts Alerts policy in place now and at the time of the reporting of the CXR. This did not overtly specify a need to alert TB.
Sent To
- Medica Reporting Service
Response Status
Linked responses
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56-Day Deadline
14 Jul 2023
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 30 May 2022, I commenced an investigation into the death of Akash Dinesh Bhudia, age 28 years. The investigation concluded at the end of the inquest on 16 May 2023. The conclusion was that Mr Bhudia died as a result of natural causes. The inquest however heard evidence in relation to non-causal concerns in relation to the reporting of chest radiographs.
Circumstances of the Death
Akash Bhudia suffered from a persistent cough from December 2021. On the 17 January 2022 he attended A&E where he underwent blood tests, chest Xray and medical reviews. The impression at this time was that he was suffering from community acquired pneumonia. He received a dose of intravenous antibiotics and intravenous fluids and was discharged from hospital with a course of oral antibiotics. Akash attended for a follow-up chest Xray on the 28 February 2022. This Xray showed progression in his left lung consolidation and showed a new consolidation in his right lung. The inquest heard that the primary diagnosis based on this Xray should have been tuberculosis. On the 4 March 2022, an emergency ambulance was called when Akash was found to be coughing and vomiting blood. Paramedics attended and provided emergency assistance. They could not however resuscitate Akash and his life was pronounced extinct by a paramedic. A post-mortem examination revealed a pulmonary abscess which was most likely to have been caused by tuberculosis. There is no evidence that any acts or omissions in the care provided to him, contributed to his death. The chest radiograph was not sent for analysis until 8 March 2022. The lack of an alert did not therefore contribute to Akash’s death.
Copies Sent To
to the Inquest. the local Director of Public Health, to the CQC and to the Royal College of Radiologists
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.