Mark Villers

Minister of State for Health and Secondary Care 

39 Victoria Street 
London 
SW1H 0EU 

Our ref: 

HM Coroner Louise Hunt 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

July 2025 

Dear Ms Hunt,  

Thank you for the Regulation 28 report of 3 June 2025 sent to the Secretary of State about 
the  death  of  Mark  Anthony  Villers.  I  am  replying  as  the  Minister  with  responsibility  for 
Secondary Care.       

Firstly, I would like to say how saddened I was to read of the circumstances of  Mr Villers’ 
death and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The report raises concerns over insufficient radiologists at Good Hope hospital to report the 
large number of CT scans undertaken over the weekend period, at the time of Mr Villers’ 
presentation to hospital on 18 May 2024. This was one of the root causes of a very subtle 
abnormality indicating aortic dissection being missed when  Mr Villers’ scan was reported. 
The  inquest  heard  evidence  that  whilst  the  situation  had  improved,  the  number  of 
radiologists was still not in accordance with Royal College of Radiology guidelines. 

In  preparing  this  response,  my  officials  have  made  enquiries  within  this  department  to 
ensure we adequately address your concerns. 

I have carefully considered the situation. Individual NHS Trusts and other employers are 
responsible for determining staffing levels and workforce composition. They are best 
placed to understand their services and the needs of their patients in order to deliver safe 
and effective care. I would expect University Hospitals Birmingham NHS Foundation Trust 
and all other NHS Trusts to ensure that their staffing arrangements, including weekend 
cover, are appropriate, following the tragic death of Mr Villers.  

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 Trusts already have a duty through the Health and Social Care Act 20081 to regularly 
review the number of staff and range of skills needed to safely meet the needs of people 
using their services. 

In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan 
later this year. This will ensure the NHS has the right people in the right places to deliver 
the best care for patients.  

I note that you have also sent this report to University Hospitals Birmingham NHS 
Foundation Trust, and Birmingham and Solihull Integrated Care Service and expect that 
they will respond regarding the concerns about the services involved. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

Minister of State for Health and Secondary Care 

1 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 18

Executive Office of the Chair & Chief Executive 

Chair 
Chief Executive 
Executive Office  

: 
: 
: 

For the attention of Mrs Louise Hunt 
Senior Coroner for Birmingham and Solihull 

Sent by way of email only: 

Dear Mrs Hunt 

Inquest touching the death of Mark Villers 
Response to Regulation 28 Report to prevent future deaths. 

I am writing in response to the Regulation 28 notice issued following the conclusion of 
the Inquest on 3 June 2025 touching the death of Mr Villers who died on 21 May 2024 at 
Good Hope Hospital (part of University Hospitals Birmingham NHS Foundation Trust 
(UHB)).  

We note your concerns are that at the time of Mr Villers’ presentation to Good Hope 
Hospital on 18 May 2024 there were insufficient radiologists to report the large number 
of CT scans undertaken over the weekend period. This was one of the root causes of 
the very subtle abnormality indicating aortic dissection being missed when the scan was 
reported. The inquest heard evidence that whilst the situation had improved the number 
of radiologists was still not in accordance with Royal College of Radiology guidelines, 
thus creating a risk of future deaths.  

We have carefully considered your concerns and would respond as follows. 

Following the incident and starting from 1st of September 2024, the provision of out of 
hours radiology reporting over weekends at Heartlands, Good Hope and Solihull 
Hospitals, part of UHB Trust, has been reconfigured to increase capacity and reduce the 
workload for individual radiologists. Previously the On-Call resident and radiologist were 
responsible for reporting all cross-sectional scans for both the Emergency Department 
(ED) and inpatients and the workload, which fluctuates, would often exceed safe 
reporting levels. 

The reconfiguration was facilitated by separating the ED reporting from inpatient 
reporting. Both are now managed across all three hospital sites. 

1-  Emergency Department Reporting:  

a.  All CT scans and urgent MRI scans from ED at Heartlands and Good 

Hope Hospitals are reported by two resident doctors working from 9am to 
5pm and from 1pm to 9pm, overlapping and doubling up between 1pm 
and 5pm, which is the busiest period.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 b.  Overnight reporting 9pm to 9am is undertaken by three resident doctors 
centralised at the Queen Elizabeth Hospital covering all UHB sites. 
c.  All resident doctor reports are issued to the clinical team pending further 

review by the On-Call consultant. 

d.  The On-Call consultant is available from 9am to 9am the next day. They 
are responsible for reviewing scans undertaken from 11pm the night 
before to 11pm on the night of their on call. 

e.  On average the On-Call consultant would review 120 scans during the day 
of their on call. These are all scans that have been previously reported so 
would take less time than reporting the scan themselves. The majority of 
radiologists find that by working for 2-3 hours in the morning, afternoon, 
and late evening with breaks in between, the number of scans to review is 
manageable and without undue stress. 

f.  The On-Call team are not reporting any inpatient scans unless they have 
been escalated by the clinical team as requiring an immediate report. 

2-  Inpatient Reporting: 

a.  Three consultant reporting sessions have been provisioned for 

Saturdays, Sundays and bank holidays, provided by two different 
radiologists - one for the AM/PM and one for the evening to reduce the 
intensity. 

b.  Each session includes reporting an average of 18 CT and MRI scans 
which is within most radiologists’ ability to do without undue stress. 
c.  Sub specialist MRI reporting is offered to other radiologists who are not 
on call as additional work to be carried out as a waiting list initiative 
(WLI) to cover their specialist areas. 

d.  We are currently in the process of establishing outsourcing of 

subspecialist MRI reporting which will provide an additional resource to 
review any subspecialist MRI scans which the radiologists covering the 
sessions have been unable to complete during their session. 

The majority of our resident doctors and radiologists, who are part of this on call / 
acute reporting rota, have found the reconfigured system has improved their 
workload making it much more manageable. 

The Royal College of Radiologists (RCR) produced a guidance document to assist 
with departmental planning.  

(https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-
publications/radiology-reporting-figures-for-service-planning-2022/) 

The RCR guidance provides the headline figure of 14 single body part MRI or 16 
single body part CT scans to be reported during each 4-hour session. There is no 
specific mention of how long reviewing a previously reported scan would take. 

The RCR guidance was published to be used for service planning as an average of 
radiologist performance across the year and the department. As quoted from the 
document linked above: “The focus of this guidance is solely on departmental 

 
 
 
 
 
 
 
 
 
 planning rather than the individuals, and it should not be used for individual 
performance management or medico-legally.”   

We do use this guidance as a benchmark to plan our service and provision it 
appropriately, but it is recognised that there will be significant variation between 
individual radiologists and in different reporting sessions and in particular during 
acute reporting sessions which service busy emergency departments where it is not 
unreasonable for radiologists to work at a higher intensity. This would be similar to 
an emergency department consultant managing patients that present themselves 
and this is something that cannot be controlled. 

In addition to the reconfiguration we have undertaken, we have also discussed the 
case at our Radiology Events and Learning (REAL) meeting, which was held on 6 
March 2025. We have also delivered an educational session around aortic 
dissection. 

While we recognise that the intensity and volume of work undertaken by the 
radiologist on the day of this particular incident and that this could have contributed 
to the error, the abnormality on the scan was very subtle. The consensus of the body 
of radiologists who attended the REAL meeting when the case was discussed was 
that it would have been very difficult to identify the subtle abnormality regardless of 
the setting. 

The Radiology team is very sorry that we let down the family of Mr Villers, and we 
apologise for this incident.  

I would like to assure you that the concerns raised within the Regulation 28 notice 
have been taken extremely seriously, which I hope is demonstrated in the steps that 
we have taken following Mr Villers’ death. 

Yours sincerely 

Deputy CEO and Chief Medical Officer