Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0439, written 26 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Aug 2025 |
|---|---|
| Reference | 2025-0439 |
| Deceased | Anne Dyson |
| Coroner | David Place |
| Coroner area | Sunderland |
| Category | Community health care and emergency services related deaths |
| Organisation named | South Tyneside and Sunderland NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Place Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: South Tyneside and Sunderland NHS Foundation Trust 1 CORONER I am David Place, His Majesty’s Senior Coroner for the City of Sunderland 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 7th March 2025 I commenced an Investigation into the death of Mrs Anne Lorraine Dyson, who died in St Benedict’s Hospice, Sunderland on 24th February 2025 aged 68 years. The Investigation concluded at the end of the Inquest on 15th August 2025. I gave a conclusion ‘Natural causes contributed to by neglect.’ The medical cause of death was: - Ia Non Small Cell Lung Cancer (Metastatic) 4 CIRCUMSTANCES OF THE DEATH Anne Lorraine Dyson died at St Benedict's hospice on 24th February 2025 having been diagnosed with metastatic lung cancer on 20th November 2024 despite being under investigation for lung disease since September 2021 and scans showing an increased growth from October 2023. An incorrect interpretation of a CT scan of 25th March 2024 led to a significant delay of many months in diagnosing a malignancy which had progressed to be terminal and could no longer be successfully treated. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are: – HM Coroner’s Courts, City Hall, Plater Way, Sunderland SR1 3AA Tel 0191 5617843 email: coroner@sunderland.gov.uk | web: www.sunderlandcoroner.co.uk The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed. I shall be glad to be told of any learning arising from this death and timescales and results of your review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st October 2025. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - • Family and their Solicitors • 4 Ways and their Solicitors and Counsel • Care Quality Commission I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated this 26th day of August 2025 Signature: HM Senior Coroner for the City of Sunderland Page 2 of 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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South Tyneside and Sunderland
NHS Foundation Trust
Sunderland Royal Hospital
Kayll Road
Sundeiland
Tyne & Wear
SR4 7TP
15 October 2025
Private & Coì nfidential
Mr D Place
HM Senior Coroner for the City of Sunderland
HM Coroner's Courts
City Hall
Plater Way
Sunderland
SR1 3AA
Dear
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Regulation 28 Report to Prevent Future Deaths - Mrs Anne Lorraine Dyson
I write in response to your Report to Prevent Future Deaths, dated 26 August2025, following
the sad death of Anne Dyson. I note that your concerns in this matter relate to processes
around sharing relevant clinical information with Radiologists and the potential impact this
has on the interpretation of imaging
As a Trust we have taken Anne Dyson's death very seriously and as you heard at the inquest,
we:have taken steps to share the identified learning with relevant Radiologists within the
Trust, highlighting the importance of Radiologists being satisfied with the extent of their
search, being aware of the risk of confirmation bias and the importance of comparing prior
qelevant' imag ing, where appropriate.
Followiirg receipt of your Report to Prevent Future Deaths, the Trust has reviewed existing
radiology processes, in liaison with 4Ways, who are an external iadiology repgrting partner
of the Trust, to consider how we can strengthen current processes both internally and
externally
The Trust's Radiology department is working to update Trust induction training to emphasise
key clinical details which must be consistently included in radiology requests to ensure the
safe and accurate reporting of these exams. To deliver this a work instruction will be
developed which will detail the required standard of clinical information required for radiology
examinations to proceed. This will also be supported by a Trust wide corhmunication to
update current staff members and there will be a regular audit of these standards, completed
by the Trust's Radiology department, to ensure compliance, with feedback provided to
individuals and whole directorates as appropriate.
ellence
in all that we do
A Standard Operating Procedure (SOP) is also being developed between the Trust and
4Ways, which is currently going through internal review and sign off, to provide a more
clearly defined clinical process for both Trust and 4Ways Radiologists, around the reporting
of images to ensure that there is a consistent approach amongst clinicians, with them being
aware of their own responsibilities. As part of this SOP, clinicians are reminded of the need,
where clinically relevant, to compare previous imaging, with the requirement to now include
reference to either a new finding or mark that no other changes are noted, to make it clear
that a comparison of relevant images has taken place.
I hope that the above addresses your concerns, but please do revert back to me should you
have any further comments or queries that I can assist with.
Yours sincerely
Chief Executive
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