Charlotte Roscoe

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Ref   Regulation 28: Charlotte Roscoe 

4th  February 2025 

For the attention of HMC Mr Pemberton  
HM Assistant Coroner for Manchester (West)  
HM Coroner’s Office  
Paderborn House 
Howell Croft N 
Bolton 
BL1 1QY 

Dear HMC Mr Pemberton, 

Trust Headquarters
Royal Bolton Hospital
Minerva Road
Farnworth
Bolton
BL4 OJR
www.boltonft.nhs.uk

Thank you for your letter dated 20th November 2024 issuing your  Regulation 28: Report to Prevent Future 
Deaths  of  the  same  date  concerning  the  sad  death  of  Ms  Charlotte  Roscoe  (‘Charlotte’)  on  22nd  January 
2024.  In  advance  of  responding  to the  specific  concerns  raised  in  your  report,  I  would  like to  express  my 
deep condolences to Charlotte’s family and her loved ones.  

Bolton NHS Foundation Trust (the Trust) are keen to assure the family and  HM Coroner that the concerns 
raised  regarding  Charlotte’s  care  have  been  listened  to  and  reflected  upon.  We  have  set  out  below  the 
Trust's response in accordance with Regulation 29(5) of The Coroners (Investigations) Regulations 2013. 

For ease of reference, the following items were identified as matters of concern in the Regulation 28 report: 

1.  During the course of evidence Royal College of Radiographer guidance was referred to, specifically 
that a CTPA scan or VQ scan where equally appropriate when considering diagnosis of a Pulmonary 
Embolism.  A  first  draft  of  an  After  Action  Report  which  was  concluded  without  Radiographer 
attendance at the after action review meeting was provided at the first part heard inquest hearing on 
1  August  2024.  This  made  reference  in  the  actions  section  of  the  report  to  the  need  to  consider 
whether VQ scans should be replaced by CTPA's for all patients suspected of having a Pulmonary 
Embolism. This action was not included in an Amended After Action report provided at the resumed 
inquest. It is unclear whether this matter has been considered. 

2.  Evidence  was  received  from  a  doctor  who  referred  the  deceased  for  a  scan,  that  she  had  thought 
she had requested a CTPA to be undertaken, but the form that was used was a request for an 'acute 
pulmonary embolus investigation' which meant that the request would be vetted, and an appropriate 
mode  of  scan  arranged  following  consideration  by  a  radiologist.  It  was  stated  by  the  doctor  that  it 
would not be normal to speak to radiology regarding a request for a scan. 

3.  In evidence from a radiologist, it was stated that a medical clinician would be expected to speak to a 
radiologist  if  there  was  any  preference  for  a  type  of  scan  to  be  undertaken  so  this  could  be 
discussed. It appeared to me that the use of the correct form, need to be specific, provide rationale 
for a specific type of scan request, and liaising with radiology as appropriate was not appreciated in 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 this  case.  As  above,  given  that  there  was  no  radiographer  involved  in  the  After  Action  Report  or 
action raised, it is unclear if this matter has been considered, or any actions taken to prevent future 
confusion. 

After Action Review (AAR) – responding to points 1 above: 
The Acute Adult Care Division was made aware of a complaint from Ms Jayne Roscoe (Charlotte’s Mother) 
on 13th February 2024 and a clinical incident was reported retrospectively by the Divisional Medical Director.  

On  initial  review  there  did  not  appear  to  be  any  concerns  in  relation  to  the  standard  of  care  provided  to 
Charlotte. However, it was felt further investigation was required given Charlotte’s age and the fact she had 
been in attendance and discharged from the Emergency Department (ED) just 24 hours prior to her death.  

The decision at this stage was to request a mortality review of Charlotte’s care and treatment whilst she was 
in the ED and to continue to investigate Ms Roscoe’s concerns via the Trust’s complaints process. The plan 
was  that  if  the  mortality  review  identified  any  concerns  regarding  the  care  provided  then  this  would  be 
escalated  as  a  PSII  (Patient  Safety  Incident  Investigation)  in  line  with  the  NHS  England  (NHSE)  Patient 
Safety Incident Response Framework (PSIRF). 

The  outcome  of the mortality  review  was that  Charlotte’s  care was rated as ‘good’  and therefore the  case 
was  not  escalated  for  a  PSII  and  the  Trust  continued  to  investigate  Charlotte’s  care  via  the  complaints 
process. A complaint meeting was held with Charlotte’s mother on 23rd April 2024 to provide full answers to 
all questions raised in the complaint. A full recording of the meeting and a follow-up letter summarising the 
outcome of the meeting was provided to the family as per standard process. 

An area of concern discussed whilst investigating the complaint was in relation to the decision to discharge 
Charlotte  from  the  ED  without  further  investigation  into  her  raised  troponin  levels  or  d-dimmer  results  and 
therefore an alternative diagnosis / treatment was not explored. As a result, the  Acute Adult Care  Division 
decided  to  undertake  a  focused  After-Action  Review  (AAR),  chaired  by  the  Divisional  Medical  Director, 
specifically to explore this decision making and to consider whether this was reasonable based on clinical 
information available at the time.  

AARs are one of the learning response tools under PSIRF, and this framework encourages organisations to 
adopt a proportionate response to patient safety incidents for learning and improvement. As such, it was felt 
an  AAR  was  the  appropriate  learning  tool  to  facilitate  a  conversation  for  that  very  focused  key  area.  The 
review  explored whether  clinicians,  with  a  similar  set  of  experience  and knowledge,  would have made the 
same decision faced with the same clinical scenario. The invitations to participate in the AAR meeting were 
therefore sent to all the Acute Divisional Medics, as they would be best placed to consider this specific area 
of potential concern. Consequently, it was not deemed necessary for a radiologist to attend. 

AARs  are  structured,  facilitated  discussions  conducted  after  an  event  or  activity  to  assess  what  occurred, 
why  it  happened,  and  how  future  outcomes  can  be  improved.  The  PSIRF  makes  no  prescription  to 
determine  what  needs  to  be  learned  from  to  inform  organisational  improvement,  and  incident  response 
activity  may  include  investigation  of  an  individual  incident  where  contributory  factors  are  not  well 
understood,  or  a  thematic  review  of  past  learning  responses  to  inform  the  development  of  a  safety 
improvement plan. 
The  AAR  concluded,  in  Charlotte’s  case,  that  assessments  carried  out,  including  investigations  and 
treatment,  were felt to  be in  line  with expected  practice. The  working  diagnosis  was Pulmonary  Embolism 

 
 
 
 (PE), and this was felt to be reasonable based on Charlotte’s clinical presentation. When this was excluded, 
Charlotte had reported that her pain had improved, resulting in the decision to discharge. At no stage was 
there any consideration of aortic dissection due to its rarity, Charlotte’s lack of risk factors and her atypical 
presentation. 

Constructive challenge was applied to the clinicians using the Bolam / substitution test; all clinicians came to 
the  same  conclusion  that  with  the  facts  presented  they  would  have  carried  out  the  same  actions  and 
discharged Charlotte from the ED.  

The  AAR  was  approved  through  the  Divisional  Governance  Board,  which  is  the  standard  governance 
process.  The potential area of learning regarding whether a CT Pulmonary Angiogram (CPTA) scan should 
be considered in place of a VQ scan for all patients suspected as having a PE, was shared with radiology 
via  the  Diagnostic  and  Support  Services  Division  governance  processes  for  their  consideration.  The  AAR 
was then disclosed to HM Coroner as per the usual disclosure processes.  
At the first inquest on  1st August 2024 matters had arisen in evidence including “identification of omissions 
and  errors  in  an  after-action  report  which  reviewed  the  circumstances  of  Charlotte’s  death”1,  and  it  was 
directed  that  further  evidence  was  required.  Additionally,  the  Trust  was  to  provide  to  HM  Coroner  ‘any 
update on the AAR conclusions and recommendations2’. 

Consequently, the  Acute Adult Care  Division sought advice from the Director of Quality Governance as to 
whether to amend the existing AAR or to completely revise the document. The advice was that the original 
AAR required an addendum to show the findings from the further investigations and to address the lack of 
observations before discharge, rather than completing a full new AAR.  It was further felt that the additional 
Radiology  evidence  and  attendance  of  the  Consultant  Radiologist  and  former  Governance  Lead  of  the 
Radiology  Department  at  the  inquest  would  provide  clarity  and  assurance  around  the  appropriate  scan 
being performed at the time based on Charlotte’s presenting symptoms.  

The addendum was completed by the original AAR author and approved through the Divisional Governance 
Board. The action regarding “the need to consider whether VQ scans should be replaced by CTPA's for all 
patients  suspected  of  having  a  Pulmonary  Embolism”  was  removed  from  the  report.  This  was  because 
following consideration, the Radiology team did not feel the proposed learning / action was appropriate on 
the basis it departed from National guidance. On reflection, the Trust acknowledge that it would have been 
clearer  to  have  kept  the  original  action  documented,  and  updated  the  outcome  of  it,  rather  than  it  being 
removed completely. 

It  should  be  noted  that  the  AAR  was  not  a  PSII;  it  was  supplementary  learning  to  the  already  completed 
mortality review and complaint investigation. 

Radiology Requests – point 2 and 3 above:  

The  request  card/form  used  in  the  ED  is  for  a  referral  for  a  scan  to  exclude  PE.  The  radiologists  are  the 
experts  who  determine  the  modality  based  on  the  Ionising  Radiation  (Medical  Exposure)  Regulations 
(IRMIR);  the technical nature  of the  imaging and  the  clinical  question  posed. The form  used  clearly  states 
that the scan is to exclude a PE and is not a specific form used to request a specific scan or modality. This 
form has been used in the trust for several years. 

1 Adjournment Directions dated 1 August 2024 
2 Adjournment Directions dated 1 August 2024 

 
 
 
 
                                                 
 Many  of  the  clinical  pathways  follow  a  set  protocol  based  on  National  guidance,  an  example  being  head 
injuries  and  NICE  guidelines.  These  set  protocoled  pathways  do  not  require  discussions  between  ED 
clinicians and Radiologists.  Excluding PE is a standardised pathway in the Trust and has been the case for 
many  years.  If  a  clinician  seeks  to  depart  from  the  set  protocols  or  National  guidance/recommendations, 
then  they  must  have  a  discussion  with  the  examining  (vetting)  Radiologist  to  explain  and  discuss  the 
rationale.  With  a  patient  presenting  similarly  to  Charlotte,  the  recommendation  from  the  Royal  College  of 
Radiologists  would  be  for  a  V/Q  scan.  If  a  CTPA  was  specifically  required,  this  would  not  be  the  primary 
modality of choice and would require further discussions between the requesting  clinician and Radiology to 
understand why a CTPA was warranted over a V/Q scan. This is custom and practice across the region.  

I would like to thank you for bringing your concerns to our attention and I hope this response provides some 
clarification.  

Should you have any further questions, please do not hesitate to contact me. 

Yours sincerely,  

Chief Executive

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20 December 2024 11:43
Inquests
RE: Regulation 28 Report - After Inquest ROSCOE 201124

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Dear Alex 

Many thanks for sending the regulation 28 report to the College. 

We’re very sorry to read about the death of Charlotte Roscoe and we would like to express our deepest condolences to 
Charlotte’s family.  

The Royal College of Radiologists (RCR) is a charity which works with our members and Fellows to improve medical care 
across the specialties of Clinical Radiology and Clinical Oncology. As part of our offering, we promote excellence in 
professional practice within our specialties, including the production of a range of publications, such as 
recommendations for the delivery of high-quality radiology services.  

Considering the nature of this report, we thought it’s pertinent to inform you of a joint RCR/ Royal College of Emergency 
Medicine document, titled Diagnosis of thoracic aortic dissection in the emergency department, which was published 
January 2024 and is subsequently undergoing a minor review. This guideline seeks to provide a consensus opinion with 
regard to which patients should be considered for CT scanning (the diagnostic modality of choice) while accepting that 
this is still an area of considerable controversy and concern. 

We are grateful to you for bringing these matters of concern to our attention. Once again, we express our deepest 
condolences to Charlotte’s family and loved ones. 

Best wishes, 

Professional Standards Manager

rcr.ac.uk  

63 Lincoln's Inn Fields, London WC2A 3JW
Charity No. 211540   

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