Janet Seddon

Chief Executive Office 
                                                                                                                                      York Hospital 
Wigginton Road 
York 
YO31 8HE 
, Chief Executive 

Direct Line: 
Email:  

19 December 2024 

Ms C Cundy 
HM Coroner for York & North Yorkshire 
By email: 

Dear Madam 

Thank you for raising your concerns following the inquest surrounding the death of Mrs Janet 
Seddon following her admission to York District Hospital. I am grateful for the extension of 
time for providing this response. York & Scarborough Teaching Hospitals NHS Foundation 
Trust (the Trust) recognises the seriousness of these findings, and I write to outline the 
actions we have taken to address the lapses identified. These measures are intended to 
reduce the risk of recurrence and improve the quality and safety of care provided to our 
service users. I note your concerns as outlined in the Preventing Future Deaths Report. 

It is to be noted that at the time of the incident the Trust followed its previous policy on 
incident management. The Trust moved to the new Patient Safety Incident Response 
Framework (PSIRF) in December 2023. Since that time revised systems and processes have 
been put in place to record, monitor, review and learn from incidents across the Trust. It is 
acknowledged that this incident should have had, under the old policy, a 72-hour report, and 
this was not undertaken. This has been reviewed within the Surgery Care Group and the new 
policy requiring either hot debrief or other form of incident response is now in place and is 
being used to proper effect. The governance structure within the Care Group, to review 
incidents, has significantly changed with a daily review of all incidents and weekly escalation 
process to Care Group Governance Lead (Consultant Anaesthetist) and Associate Chief 
Nurse.  

Following the introduction of the new PSIRF framework the Trust updated the Incident 
Management Policy and Procedures (March 2024) and its Duty of Candour Policy, now called 
Compassionate Engagement and Duty of Candour Policy (June 2024) which are available 
should you wish to have sight of them.  

 
 
 
 
  
 
 
 
 
 
 I will address your specific concerns as follows: 

3a) the very significant delay in addressing whether the missed abdominal pathology 
was the result of a reporting error; 
3b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of 
the error;    

When the possible radiological misinterpretation on the CT scan was identified on 07/02/2023 
this was acted upon immediately, and Mrs Seddon underwent surgery the same day. It is 
accepted that following this immediate response, there was a delay in confirming whether this 
was a radiological error (as opposed to a discrepancy) and, once this was identified, a further 
delay in confirming the level of harm.   

The radiology reporting team are encouraged to report discrepancies as part of a learning and 
improvement culture and communications have been regularly reviewed in this regard. 
Following this case being highlighted to the team there is now a much-improved awareness 
of, and engagement with, the discrepancies process. 

The Trust Radiology Duty of Candour Standard Operating Procedure (SOP) (available should 
you wish to have sight of this) describes how discrepancies are assessed to establish if 
radiological errors have occurred and how these are then disclosed to clinicians to evaluate 
degree of harm and inform duty of candour conversations if required. This SOP is in line with, 
and applies, national Royal College guidance to our processes. It was last revised in July 
2024, before this inquest, and that update included specifying the one-week turnaround 
timeframe for reporters responding to a candour panel, improving efficiency from the 
Radiology side of the process, and a two-week response timeframe for treating clinicians to 
respond to Radiology letters disclosing confirmed radiological errors and requesting feedback 
on the degree of harm. A governance structure for reporting and escalation was added for 
discrepancy cases which involves the review of incidents at the weekly Senior Leadership 
Team (Assistant Chief Nurse, Assistant Chief Operating Officer, Care Group Director and the 
governance team) meetings, where the lack of feedback on the level of harm can be 
escalated.   

Further updates to the SOP have been developed to clarify that the receiving treating 
clinician’s Care Group governance team should be copied into the initial correspondence to 
the clinician, and if required escalation for feedback on level of harm will take place with the 
Cancer, Specialist and Support Services (CSCS) Care Group Director contacting the Director 
of the respective Care Group. This will ensure a more timely outcome regarding level of harm 
and in turn a duty of candour conversation with patient and/or family with the treating clinician, 
supported by a radiologist. These updates will be submitted to the next Radiology Directorate 
Meeting and on approval to CSCS Care Group Board for virtual agreement on 12/12/24.  

3c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner;  

The surgeon reports that he was open with the patient about the missed pathology and the 
need for second scan but the significance of this was unknown at the time. It was noted that 
the patient had full capacity, and she was very clear with the surgeon that she did not want 

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 her family to know that she was going for surgery. This was explained to the family following 
her death via a letter sent to them on 13/02/2023. However this did not make reference to a 
radiological discrepancy.  

The incident form provided to the Coroner on 26/02/24 confirmed that there had been a 
radiological error. As this had (incorrectly) been deemed a low harm incident, statutory duty of 
candour did not apply.  

3d) the absence of evidence that all relevant learning arising from the above has 
occurred and any actions arising from such learning have been completed;  

This case was discussed at the Radiology Events and Learning Meeting (REALM) in 
November 2023. Minutes are not kept as per Royal College of Radiologists guidance and all 
cases are anonymised, to encourage open discussion. Attendance at REALM is high within 
the Trust and participation is monitored and discussed at individual reporter’s annual 
appraisal. 

e) the potential risk of death to others in the event of a recurrence of any of the 
above.  

As outlined above our processes for reviewing and learning from potential radiological errors, 
and fulfilling duty of candour where required, have been strengthened. We also have in place 
a revised Incident Management Policy and a revised Duty of Candour Policy further 
strengthening our systems and processes.   

Conclusion 

We hope that this information provides you with assurance that the Trust takes its 
responsibilities to be open and honest with patients very seriously. We have a number of 
systems and processes in place to ensure that these are effective. The Trust has learned from 
this incident and have refined our processes as a result. This will continue to be monitored 
carefully through our governance and assurance structures.  

Yours sincerely 

Chief Executive  

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