During the course of the Inquest evidence gave rise to the following matters of concerns:- The Consultant Radiologist who performed the procedure confirmed that the post-operative checks were not compliant with the Trust's Protocol. Only 2 complete checks were carried out (at 10.45 and 11 am): The check at 11.50 was not complete. There were no further post-operative checks documented on the observation sheet after 11.50, despite the concerning observations at that time_ The Consultant Radiologist gave evidence that had the appropriate post-operative checks been carried out; the bleed was likely to have been detected at an earlier stage_ He further confirmed that had the bleed been detected at an earlier stage Mrs Walker's death is likely to have been avoided on the gth July 2016 The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: The failure of the porters to collect the patient: He stated that the failure of the porters to attend, was reported as a serious incident: He stated that this issue has still not been resolved and is an ongoing issue within the Trust: The failure of nurses on the ward to take her back: (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure)_ IlI: The Consultant described a "chaotic situation" with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring: The lines of clinical accountability post-procedure, was unclear: The radiologist confirmed that Mrs Walker was no longer the responsibility of the radiology team after the procedure, as she should have gone up to the ward: The ward however were concerned with her clinical parameters and considered that she should remain with the radiologist I(husband) provided guidance from the BMJ setting out the suggested post-biopsy observations This included observations every 15 minutes for the first 2 hours and then every 30 minutes for 2 hours thereafter: would respectfully request that the Trust consider the Policy that it has in place, in light of the BMJ recommendations_ 2 incident report forms were completed in relation to Mrs Walker's death: (Form number 52695 and Form number 53952): The outcome of the main incident report form (52695) concluded that appropriate care was given and this was not considered a Serious Incident: This conclusion was at odds with the evidence heard from the Trust's Consultant Radiologist: It was also at odds with the Trust's Protocol for post-operative monitoring and the recorded post-operative observations