(1) The two consultant radiologists at the district general hospital saw a need for a specialist opinion to assist in the interpretation of complex and abnormal CT and MRI scans. There was no clear prescribed pathway for them to obtain direct access to neuroradiologists at the tertiary centre. In consequence, an inapposite referral was made to a neurosurgical unit, which did not assist the resolution of the uncertainties regarding the correct diagnosis. My concern is that if much needed linkages between relevant groups are not appreciated and made effective, then the value of having a specialist resource could be lost in future cases, not only in the medical specialty and hospital involved here, but in many others as well.

(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.

The pertinent features of the miscommunication were:

1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalous – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.

(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -

(a) Make plain the circumstances in which it should be used – and where it is not appropriate.

(b) The information required to be included.

(c) The precise issues upon which guidance is sought.

If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.

It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.