Gemma Marshall

Steve Eccleston 
Assistant Coroner for the West Yorkshire area  
HM Coroner’s Court 
Cater Building 
1 Cater Street 
Bradford 
BD1 5AS 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

24 February 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Gemma Suzanne Marshall 
who died on 15 March 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
January 2025 concerning the death of Gemma Suzanne Marshall on 15 March 2024. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Gemma’s family and loved ones. NHS England 
are  keen  to  assure  the  family  and  the  Coroner  that  the  concerns  raised  about 
Gemma’s care have been listened to and reflected upon.   

Your Report raises concerns about the interpretation of a CT scan, which showed that 
Gemma’s  gastric  band  had  slipped  and  was  out  of  position.  You  reported  that  the 
slippage was not commented on or subsequently reported by the radiologist and noted 
that this was due to lack of familiarity with how slipped bands present, compounded 
by the increasing rarity of the procedure as well as the CT scan having been reviewed 
by an outsourced third-party radiologist without the relevant specialism in abdominal 
or bariatric issues. You considered that the knowledge gap around the presentation of 
slipped bands is an issue of concern nationally. 

My response to your concerns has been informed by the Imaging and Transformation 
Programme Team at NHS England. Teleradiology is the transmission of images and 
associated  data  between  locations  for  the  purpose  of  primary  interpretation  or 
consultation  and  clinical  review.  Such  processes  include  the  sharing  of  patient 
identifiable  information  within  and  among  organisations  and  across  international 
boundaries. Teleradiology reporting is widely used across the NHS for out of hours 
emergency  reporting  of  CT  examinations  and  other  modalities,  where  clinically 
required to support urgent patient care. In addition, teleradiology reporting can also be 
outsourced to companies to deliver routine reporting where there is a local requirement 
to support the expected report turnaround times within imaging services.  

To ensure the reporting clinician working in the imaging department has appropriate 
clinical information to formally report on examinations, it is essential that all referrers 
requesting  imaging  examinations  provide  clear,  concise,  and  relevant  clinical 
information to justify the examination, including any medical history that is relevant to 
the  clinical  examination  requested.  Trusts  that  outsource  imaging  reports  to 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
  
 
 
 teleradiology  providers  should  ensure  the  teleradiology  provider  has  access  to  the 
same patient referral form as reporting staff working within the imaging department.  

All  NHS  Trusts  that  outsource  reporting  of  imaging  examinations  to  teleradiology 
companies  remain  responsible  for  the  patient.  Trusts  should  have  robust  contract 
arrangements  in  place to ensure  the  teleradiology  service  meets  the  Trust’s  clinical 
and  governance  standards,  overseen  by  regular  performance  and  management 
meetings between the teleradiology company and the Trust, to ensure that the Trust’s 
standards are delivered. 

In  order  to  learn  from  reporting  discrepancies  or  clinical  incidents,  all  reporting 
discrepancies  should  be  reviewed  at  the  Trust’s  Radiology  Events  and  Learning 
Meeting 
include  any 
relevant teleradiology cases, with feedback given to the teleradiology provider on the 
outcome of the case, to ensure learning is shared with the original reporter. 

forum.  The REALM  should 

(REALM) or  equivalent 

In 2019, the Healthcare Safety Investigation Branch (HSIB), now the Health Services 
Safety  Investigations  Body  (HSSIB),  issued  an  investigation  into  ‘Failures  in 
communication  or  follow-up  of  unexpected  significant  radiological  findings’.  This 
identified a series of safety recommendations, which included that the Royal College 
of  Radiologists,  working  with  the  Society  of  Radiographers  and  other  relevant 
specialties through the Academy of Medical Royal Colleges, developed: 

•  principles upon which findings should be reported as ‘unexpected significant’, 

‘critical’ and ‘urgent’ (safety recommendation 1) 

•  a  simplified  national  framework  for  the  coding  of  alerts  on  radiology  reports 

(safety recommendation 2) 

•  a  list  of  conditions  for  which  an  alert  should  always  be  triggered,  where 

appropriate and feasible to do so (safety recommendation 3). 

The contents of the HSIB’s investigation report were considered by NHS England’s 
Imaging Transformation Team, as part of a working group overseeing NHS England’s 
response  to  the  Parliamentary  &  Health  Service  Ombudsman  (PHSO)  Unlocking 
Solutions in Imaging: working together to learn from failings in the NHS 2021 report 
into  imaging  within  the  NHS.  To  support  this  work,  significant  investment  has  been 
made to improve IT and digital infrastructures within imaging services and additional 
funding will be allocated in 2025/26.  

In response to the PHSO report, the Academy of Medical Royal Colleges published 
the  report  ‘Alerts and notification of  imaging  reports:  Recommendations’  in  October 
2022 to support critical and unexpected findings. 

All Trusts should ensure that they are following these published recommendations and 
that they work with their teleradiology company to embed their local alerting processes 
into the teleradiology workflow. On 31 January 2023, NHS England issued a Patient 
Safety  Update  to  notify  Trusts  that  the  Academy  of  Medical  Royal  Colleges’  ‘Alerts 
and Notification’ paper had been published. 

The Quality Standard for Imaging (QSI) launched in July 2024 in collaboration with the 
College  of  Radiographers,  supports  improving  standards  of  imaging  services.  It  is 
expected that all providers of imaging services will work towards this QSI or equivalent 

 
 
  
 
 
 
 quality standard, to ensure their services are managed effectively and are safe for all 
users. 

With a few exceptions, the reporting of emergency CT scans out of hours is considered 
to be a core competency and is routinely delivered by radiologists with other specialist 
interests, both across the NHS and teleradiology companies.  

NHS England will work with key partners, including the Royal College of Radiologists, 
and via the 22 imaging networks operating across the NHS, to support the governance 
of teleradiology contracts going forwards.  

NHS England’s North East and Yorkshire regional colleagues have also engaged with 
West Yorkshire Integrated Care Board (ICB) on the concerns raised in your Report. 
We have been advised that Calderdale and Huddersfield NHS Foundation Trust have 
conducted  an  After  Action  Review,  and  the  findings  and  learnings  from  the 
investigation have been shared with staff involved in the incident, as well as all relevant 
areas  across  the  organisation.  The  Trust  have  also  undertaken  a  REALM  teaching 
session, which included a case study and learning around gastric band functioning, 
positioning,  complications  (including  band  erosion)  as  well  as  how  these  should be 
radiologically  managed  in  conjunction  with  the  treating  team.  In  addition,  the  Trust 
have confirmed that discrepancies in the radiological reporting have been shared with 
the  relevant  external  reporting  provider  who  reported  on  the  CT  scan,  who  will 
undertake  their  own  investigation.  Discrepancies,  alongside  other  performance 
markers, are routinely discussed with the external reporting provider as part of their 
contracting agreement.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Gemma, are shared across the NHS at both a national and regional level and helps 
us to pay close attention to any emerging trends that may require further review and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

Assistant Coroner Mr Steve Eccleston  
HM Coroner's Court 
Cater Building 
1 Cater Street 
Bradford 
BD1 5AS 

31st January 2025  

Sent by email: 

Dear Mr Eccleston, 

Royal College of Radiologists Response to Regulation 28: Prevention of Future 
Deaths report issued on 2nd January 2025 in relation to the death of Ms Gemma 
Suzanne Marshall. 

I was very sorry to read about the death of Ms Marshall and I would like to express my 
deepest condolences to Ms Marshall’s family.  

We take the matters raised in your report very seriously and I hope this reply will be helpful in 
outlining how we are committed to learning from the report and supporting our members and 
Fellows to develop and maintain excellent medical care.  

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. We promote excellence in professional practice within our specialties and we 
produce a range of publications, including standards for the delivery of high-quality radiology 
services.  

Annually, the RCR publishes a Clinical radiology census report and a recurring theme each 
year is the shortfall in UK radiologists and the widening gap between the capacity of our 
radiology workforce and the escalating demand for imaging services. The data in our census 
is intended to inform Government, NHS and trust and health board leaders so that they can 
take meaningful action to grow and support the radiology workforce.  

Managing the imaging of a patient with abdominal pain, including a patient who may have a 
complication of a gastric band, is within the scope of the Clinical Radiology Specialty Training 
Curriculum although gastric bands are not specifically listed in the curriculum document. This 
is because it is a rare condition, and it is not possible to provide a comprehensive list of 
every rare medical condition or implantable device which might be encountered or which 
might cause harm to a patient. Similarly, while the complications of gastric bands are also 
well covered by several educational papers published in the radiology literature, it is not an 

 
 
 
 
 
 
 
 
 
 
 area which is covered by bespoke guidance from the RCR, nor from any of the affiliated 
Special Interest Groups in radiology within the UK. I am also not aware of any bespoke 
guidance from any other similar organisation in other countries around the world. This does 
not reflect a lack of importance but because it is not possible to issue detailed guidance 
covering every individual condition and clinical scenario which might arise. 

The RCR produces guidance on Standards for interpreting and reporting of imaging 
investigations which recommends that reporters should only work within their scope of 
practice and competence. All radiologists have a mixture of general and subspecialty 
radiology skills although their area and degree of specialism will vary. Most hospitals have a 
general diagnostic on-call rota that is covered by a wide variety of radiologists, all of whom 
are competent at reporting general imaging (like a CT of a patient’s abdomen in the context 
of abdominal pain, as in this case) but who also have one of many specialist areas of 
practice. In the on-call setting radiologists will therefore more often be reporting scans that 
are outside their specialist area of interest than within it. 

Given the current state of staffing and IT provision in the NHS it is not currently possible for 
all emergency imaging to be reported by a local radiologist with sub-specialty expertise in the 
relevant area. This is as true of other sub-specialty areas of radiology (chest, neurology, 
musculoskeletal, gynaecology, paediatrics etc) as it is of abdominal imaging. The fact that the 
reporting radiologist had a specialist interest in a different area does make it inevitable they 
will be less expert at identifying very rare pathology in the abdomen. If the treating team have 
ongoing concerns, then in most imaging departments there is typically the opportunity to 
discuss the imaging with a local radiologist with greater relevant subspecialist knowledge 
during the working week. Some places may have an informal mechanism to seek immediate 
peer support from colleagues with different specialist interests but formal arrangements out 
of hours tend to map to referral pathways for the patient themselves and are variably 
available. 

The RCR supports the development of clinical networks, and it is conceivable that in future 
an integrated network of linked hospitals could provide specialty reporting for a group of 
hospitals. However, the current IT infrastructure available remains a significant barrier in 
most places across the UK. 

Although imaging is very important patients must always be treated according to their clinical 
condition and not on the presumption the imaging is infallible. The RCR’s Standards for 
interpreting and reporting of imaging investigations guidance makes clear the importance of 
communication, including the communication of uncertainty where necessary. It outlines that 
a radiology opinion is informed by any given clinical history and in turn should guide further 
clinical assessment and management. 

A specific difficulty around imaging gastric bands is that this has become a less common 
procedure, with other procedures like gastric sleeve operations now being more frequently 
used. There has also been centralisation of NHS bariatric services so many receiving 
clinicians and also radiologists will not have regular experience of assessing these cases, 
even if they are a specialist gastrointestinal radiologist as some referrals may go beyond 
even a regional centre.  

 
 
 
 
 
 Gastric bands do sometimes move out of position. Slippage of a gastric band, however, is 
not in and of itself a surgical emergency unless accompanied by clinical features which 
indicate serious complications. These features are more usually obstructive symptoms rather 
than symptoms of gastric infarction. Given the circumstances of Ms Marshall’s death and 
because she was considered well enough to be self-caring and to be discharged home at the 
time of the CT, even if it had been recognised that the gastric band had slipped on the CT, 
surgical intervention may well not have taken place within the two-day time window between 
her initial presentation and subsequent death.  Therefore, tragically, interpretation of the CT 
may not have been the only factor that required to change in order for Ms Marshall’s death to 
have been prevented. 

The use of outsourcing companies is becoming increasingly frequent in the UK, including out 
of hours. There are many reasons for this including to purchase additional reporting capacity 
when a trust does not have this locally or where it wishes to create an environment felt more 
likely to retain the few radiologists it currently has. There are also many reasons relating to 
the relative working environments within the NHS and within an outsourcing company which 
are causing radiologists to choose to do such work. 

A properly staffed and funded radiology service within an acute hospital is vital to support 
patient care but outsourcing is commonly used as a supplementary provision. That her scan 
was outsourced is unlikely to have made the misinterpretation of Ms Marshall’s CT any more 
likely.  If the scan had been reported in-house by a local radiologist, it is no more likely that it 
would have been allocated to have been reported by a radiologist with specialist expertise in 
abdominal imaging and equally likely that the scan would have been reported by an inhouse 
radiologist with specialty expertise in some other non-abdominal area.  Many outsourcing 
companies will report a much larger volume of work than a single trust and although it did not 
happen on this occasion, they may be in a better position than a single trust to attempt to 
allocate work by special interest area in an emergency setting because they will have 
multiple radiologists reporting simultaneously rather than a single person in each place 
individually “on call” only for their trust. There may be less clinical contact with a radiologist in 
an outsourcing environment and they may not have an ongoing clinical working relationship 
with referrers, but the expected standard of reporting is not lower and the large majority of 
radiologists doing this work are NHS consultant radiologists who additionally do some 
outsourcing work.  

It is internationally accepted that even the best trained radiologists working in an optimal 
environment will occasionally issue reports which are subsequently shown not to be 
completely accurate. Discrepancy is a complex area in radiology and there are many 
potential causes which are not all due to lack of observation or error in interpretation. At least 
4% of radiology reports, of which there are many millions in the UK every year, are 
discrepant to some extent. It is therefore important that radiology is interpreted in clinical 
context and with appropriate safeguards. While ideally a service would be constructed to 
minimise the number of such reports they can never be fully eliminated and RCR guidance 
places emphasis on learning from these events as described in the Standards for radiology 
events and learning (REAL) meetings and allied structure around the REAL process. The 
RCR does publish educational material including anonymised cases and I have asked the 

 
 
 
 
 
 relevant editor to consider this case theme and signpost a suitable anonymised CT (from a 
different patient).  

Most outsourcing contracts will include some specification of who will be acceptable to 
interpret imaging, within what timescale and there is also typically some quality assurance 
written into the agreement. Outsourcing radiology companies typically have greater double-
reporting and better metrics on the radiologists who work for them than NHS trusts. There 
exists a tension that NHS departments require a minimum radiology provision to keep the 
service running but that the more challenged a department becomes the less attractive it is 
as a place of work which further increases any requirement to outsource. 

There is limited data on whether outsourced reports actually do have a higher level of 
discrepancy, and this is a contentious area with strong views on either side. When examined 
in the National Emergency Laparotomy Audit (most recent data on this metric was up to 
November 2020) there was an approximately 2% difference between in house and 
outsourced reports within the context of ten-fold higher variation in rate between individual 
hospitals. 

I am grateful to you for bringing these matters of concern to our attention and for giving us 
the opportunity to respond. Once again, I express my deepest condolences to Ms Marshall’s 
family and loved ones. 

Yours sincerely, 

RCR President