Matthew Goldsmith

PRIVATE AND CONFIDENTIAL 
Ms Nadia Persaud 
HM Area Coroner 
Walthamstow Coroner’s Court 
Queens Road 
London 

Date:      20 November 2025 

Legal Services
Queen’s Hospital
Rom Valley Way, Romford, RM7 0AG

Regulation  28  Report  on  the  death  of  Mr  Matthew  Goldsmith  – 

Dear Ms Persaud,  

Thank you for your Regulation 28 Report issued on 9 October 2025 in relation to the 
death  of  Mr  Matthew  Goldsmith.  Barking,  Havering  and  Redbridge  University 
Hospitals  NHS  Trust  (BHRUT)  has  carefully  considered  the  matters  of  concern 
raised by the Coroner, acknowledges these findings, and has implemented an action 
plan to reduce the risk of a recurrence of missed radiological findings. The Trust also 
extends its sincere condolences to Mr Goldsmith’s family. 

The  matters  of  concern  identified  in  the  Regulation  28  Report  and  the  Trust’s 
responses are set out below. 

Missed Abnormal Findings on CT Scans and the Coroner noted the absence of 
a formal peer review system for Radiology reporting, as required by the Royal 
College of Radiologists RCR). 

The full concerns were:  

1.  Abnormal findings in the abdominal vascular system were apparent on 3 CT 
scans from January 2020 to October 2024 but not reported by the reviewing 
radiologists. 

2.  In  January  2020  a  CT  trauma  scan  was  carried  out  following  a  road  traffic 
collision. This scan showed an occluded right common iliac artery and origin 
of  inferior  mesenteric  artery.  Whilst  these  findings  were  not  relevant  to  the 
clinical condition at the time, they should have been reported. 

3.  In  April  2024  the  CT  scan  of  the  chest  showed  occlusion  of  the  infrarenal 
aorta,  bilateral  common  iliac  artery  and  right  external  iliac  artery. There  was 
severe  stenosis  of  the  superior  mesenteric  artery  in  its  mid  segment.  The 

Page 1 of 5 

 
 
             
 
 
 
 
 
 
 
 
 
 
 
 
 latter  finding  was  of  direct  clinical  interest.  None  of  these  findings  were 
reported. 

4.  On 10 October 2024 an abdominal CT scan showed occlusion of the superior 
mesenteric  artery  mid  segment.  This  was  directly  relevant  to  the  clinical 
condition and it was not reported. 

5.  The Royal College of Radiologists Guidance requires peer review of 5-10% of 
reported radiology cases as part of a Trust’s quality assurance process. At the 
date of the inquest, Barking Havering & Redbridge NHS Trust does not have 
such a peer review system in place. 

6.  In  light  of  the  number  of  missed  radiological  findings  in  this  case,  by  3 
separate  radiologists,  it  is  of  concern  that  the  peer  review  process  is  not 
taking place at the trust. 

Trust Response  

Following receipt of the Regulation 28 Report on 9 October 2025, a multidisciplinary 
review  meeting  was  convened  on  15  October  2025.  This  meeting  included  senior 
clinical and managerial representatives from Radiology, Nursing, Governance, Legal 
Services,  and  the  Medical  Directorate  to  review  the  findings  and  develop  a 
comprehensive action plan. 

The  Trust  recognises  that  the  missed  findings  represent  a  serious  quality  concern 
and accepts the Coroner’s recommendations in full. The following actions are being 
implemented: 

The Radiology senior team are in the process of outlining a Radiology Governance 
Framework (project plan) by aligning workstreams, responsible leads and measuring 
key outputs by each of the governance domains and fundamentally ensuring that this 
links  back  to  the  SEIPS  plan  (Systems  Engineering  Initiative  for  Patient  Safety)  
methodology.  This is a  working  plan  which  in  the  coming months will  be  discussed 
with  clinical  and  non-clinical  staff  for  oversight  and  approval.  Within  this  plan  there 
are  essential  domains  which  responds  to  the  coroner’s  concerns  and  will  be 
standalone  items  to  ensure  that  they  are  progressed  without  delay  and  detailed 
below including an action plan. With the framework there will be enhanced oversight 
and  assurance 
the  Corporate  Quality  &  Safety  Team,  Radiology 
Governance Forum, and Legal Services. 

through 

• 

Introduction  of  a  SEIPS-based  project  to  identify  and  address  human  and 
system factors contributing to reporting discrepancies. 

•  Development  and  implementation  of  a  peer  review  process  for  Radiology  in 
alignment with RCR guidance, ensuring systematic case review and feedback 
mechanisms. 

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 Action Plan  

Action Area 
1.A project plan to 
be developed to 
outline 
implementation of a 
rapid review of 
discrepancies using 
SEIPS methodology 

2. The review of the 
wider Radiology 
Governance 
framework and the 
establishment of  
workstreams 
Clinical & 
Governance Lead 
consultants in 
Radiology to 
introduce Peer 
Review Process 
and required 
assurances 

Timeline/lead 
12 December 2025 
– Feb 2026 

 Radiology 
Professional Lead, 
Consultant 
Radiologist and 
Service 
Development 
Manager 

12 December 2025 

 Radiology 
Governance Lead 
And Radiology 
Clinical Lead 

Specific Actions 
Implement dual-
track PSIRF (SEIPS 
+ Systems Thinking) 
for discrepancy 
learning. 

Outputs 
≥90% discrepancy 
reviews completed 
monthly using SEIPS 
process. 

Action plan 
developed for 
workstreams  

Addresses external 
factors learning from 
diagnostic errors and 
reduces recurrence risk 
whilst also maintaining 
principles of Radiology 
events and Learning  
meeting (REALM) 

Introduce a peer 
review process 
within Radiology to 
further identify, 
discuss, and learn 
from interpretation 
discrepancies in 
addition to REALM. 

Monthly peer reviews 
completed; learning 
outcomes presented in 
governance meetings; 
summary dashboard 
produced showing 
learning and outcomes 
and themes identified. 

Radiology will 
conduct 3% each 
month rising to 5% 
from June 2026  

Supports quality 
improvement, PSIRF 
learning culture and 
professional 
development 

The  specific  actions  arising  from  Patient  Safety  Incident  Investigation  (PSII)    have 
been included for assurance:  

1.  A  grand  round  teaching  session  will  be  delivered  on  11  December  2025  by 
the  Surgical  Clinical  Group  around  acute  and  chronic  presentation  of 
mesenteric  arterial occlusion.  The  Grand  round  is a  regular learning  session 
led  by  the  Director  of  Medical  Education  to  review  incidents  where  learning 
has  been  established.  At  this  grand  round  colleagues  from  the  upper 
Gastrointestinal and Vascular teams were present.   

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 2.  The  case  was  presented  at  the  BHRUT  Patient  Safety  Summit  (PSS)  on  23 
July  2025  for  Trust  wide  learning.  The  PSS  is  a  monthly  Trust  wide  open 
forum  for  staff  to  attend  and  learn  about  incidents  that  have  significant 
learning outcomes. This embeds shared learning for all and is also available 
on the intranet for staff that are unable to join.   

3.  BHRUT has implemented Electronic Patient Record (EPR) system from week 
commencing 08 November 2025 which will enable Radiologists and referring 
clinician’s  to  record  real-time  decisions  and  clinical  advice  directly  into  the 
patients record.     

Plain Film Peer Review  
Within Radiology, the plain film x-ray specialty has already commenced peer reviews 
which  has  been  in  place  for over 12 months  and  from  July 2025,  the  specialty  has 
managed  to  peer  review  5%  of  cases  and  is  being  led  by  the  Radiology  Specialty 
lead. A Standard operating procedure was created and will be replicated to the other 
modality/specialty areas. A shared governance file stores all reviewed cases.  

Teleradiology Governance 

BHRUT use Everlight outside of normal working hours to ensure 24 hour imaging 
cover.  

Should there be a discrepancy the imaging/report is reviewed at REALM, letters to 
Radiologists are produced where needed, and uploaded to Everlight’s Governance 
Portal for action. Everlight then conducts a peer review and produces a governance 
report (confidential).Everlight operates a structured clinical governance system, 
which includes: 

•  A blame-free learning culture with rigorous peer review. 
•  2–10% of all Radiology reports subject to structured internal peer review. 
•  Review of all Level 1 and 2 discrepancies by the Medical Leadership Council 

(MLC) 

•  Personal reflection learning forms for Radiologists involved in significant 

discrepancies. 

•  Regular Clinical Governance Everlearning webinars are held, open to 

all Everlight Radiologists, where cases identified via the peer review process 
are shared and learning points reinforced. These webinars are also recorded 
and made available offline for review. Everlight Radiologists are required to 
attend or view the majority of these meetings 

•  Learning is also shared via monthly Everlearning Bulletins which contains 

details of interesting cases and learning points, and regular email newsletter 
to all Radiologists 

•  Use of discrepancy data to identify trends and drive system improvement. 

These processes are widely recognised as more rigorous than standard NHS 
governance models and BHRUT Radiology aims to mirror best practice for 
peer reviews and discrepancies to Everlight’s process. 

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 The  Trust  takes  the  Coroner’s  findings  extremely  seriously  and  is  committed  to 
ensuring  that  the  learning  from  this  case  translates  into  measurable  and  sustained 
improvements in radiological practice. 

We thank the Coroner for highlighting these critical issues. The Trust is fully 
committed to completing all actions within the specified timelines, with progress 
rigorously monitored through established governance processes. We will ensure that 
these measures are fully implemented and embedded into routine practice, driving 
sustained improvements in patient safety and the quality of radiological care. 

I would be happy to meet with you to discuss this response if that would be helpful. 

Yours sincerely, 

Chief Executive 
Barking, Havering and Redbridge University Hospital.  

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