Man Ng

Care Quality Improvement Directorate 
Royal College of Physicians 
The Spine  
2 Paddington Village 
Liverpool 
L7 3FA 

Assistant Coroner R Brittain, 
Manor House Dr 
Coventry 
England  
CV1 2ND 

30 January 2025 

Subject 
Royal College of Physicians response to Regulation 28 report to prevent future deaths  

Dear Assistant Coroner R Brittain,  

The Royal College of Physicians (RCP) notes with concern the content of the Regulation 28 report for 
the prevention of future deaths related to the death of Man Yin ‘Anita’ Ng. We send our sincere 
condolences to the family of Mrs Ng. 

This regulation 28 report is addressed to the RCP, and we have consulted neurology experts, acute 
medicine and general medicine experts, including our Patient Safety Committee.  

The RCP notes the matters of concern raised in this report, particularly the concerns about the 
processes surrounding the treatment of subarachnoid haemorrhage. Many of those who present 
with such a clinical problem in the acute hospital setting will be picked up by emergency 
departments and transferred to the neurosurgeons for further management directly. In this case, 
Mrs Ng, who presented to a centre with a dedicated neurosurgical unit (at Coventry and 
Warwickshire hospital), did not have the delay which can be associated with transfer from centres 
without neurosurgery on site. However, the Royal College of Physicians wish to make clear that in the 
case where there is no neurosurgical unit, for example, a district general hospitals, pathways should 
be in place and do exist for transfers to be facilitated as quickly as possible for patients to receive 
specialist treatment. There can be delays in transfer when the neurosurgical units are full and this 
might be when a patient is admitted into an acute medical admissions unit to await transfer. We also 
note the nine hour delay from the time of presentation to the emergency department until review by 
a doctor and we continue to campaign on this matter as we hear from our clinicians the very 
concerning impact on patient outcome, as a result of unacceptable delays in emergency care.  

Whilst awaiting transfer, the neurosurgeons may request further imaging such as a CT angiograph to 
identify aneurysms or bleeding points, although in many cases as soon as the original bleed is 
identified, permission will be obtained to proceed to an angiography and consent obtained as this 
investigation involves the use of contrast. Furthermore, occasionally, those presenting with classical 
signs and symptoms of a subarachnoid haemorrhage may initially have normal imaging and require a 
lumbar puncture which can delay diagnosis but, as soon as it is identified, patients are discussed with 
the neurosurgeons. Ideally, a patient should be transferred for intervention as early as possible. 

 
 
 
 
 
 
  
 
 
 There is variability in the interventional radiology services which may be available in relation to 
timing of intervention but also the safest time to proceed. In Mrs Ng’s case there were delays due to 
issues with resources and staffing. These are noted to be relatively unusual in our experience. If 
indeed, Mrs Ng had presented to a hospital without a dedicated neurosurgical unit, the delay may 
have been greater. Furthermore, we recognise that the procedure itself carries a haemorrhage risk 
and sadly for Mrs Ng’s family, we will not know whether, even if she had had the intervention in a 
timely manner, the aneurysmal sac/blood vessel walls would have been so thin and friable that she 
would sadly have been at risk of a re-rupture during the intervention. The risk with all intracranial/ 
subarachnoid haemorrhages is that they can extend. 

As you mention within the Regulation 28, much of the input into the treatment of such patients falls 
under the purview of interventional radiologists and our physicians are mainly involved in the initial 
identification of a subarachnoid haemorrhage, initial referral and sometimes investigation and where 
necessary, if someone needs repatriation acceptance back for rehabilitation.  Whilst we acknowledge 
your comments about interventional radiologists not having direct admitting rights, there is safety for 
such patients to be admitted under core specialties such as neurosurgery. The safety, for example, of 
those patients requiring angioplasty instead of vascular surgery in district hospitals may fall under 
medicine.  This should provide oversight, for example, in a way the bloods can be rechecked after the 
intervention and pre/post hydration can be organised for those at risk of kidney failure due to the 
use of contrast.  

We would support the NICE guidance of an MDT approach, with a discussion between interventional 
radiology and neurosurgery to ensure the best approach and ofcourse, patient and carer 
involvement.  

In asking for our guidance as to who is best to manage patients with this condition, we would state 
that the neurosurgeons and linked MDT are best placed to manage these patients, especially due to 
the fact that not all centres have a dedicated neurosurgical service or neuro-interventional service 
and the importance of such patients being managed by these specialist teams rather than delay 
treatment options. This enables appropriate protocols to be in place for the safe and effective use of 
such services and offers the best outcomes for patients. This said, unfortunately the nature of 
subarachnoid haemorrhages is such that re-rupture is unpredictable, including primary rupture, and 
even the best neurosurgeons who manage the complex aneurysms cannot predict whether someone 
may rupture before intervention can be done in a safe and timely manner. Without an anaesthetist 
present, it would not have been safe to proceed and it may have been that if the thrombectomies, 
which took priority on the 20 Jan 2025, had been delayed that the patients may have suffered similar 
catastrophic consequences.  

Indeed, the NICE guidance of the management of aneurysms causing subarachnoid haemorrhages is 
clear: “An interventional neuroradiologist and a neurosurgeon should discuss the options for 
managing the culprit aneurysm, taking into account the person's clinical condition, the characteristics 
of the aneurysm, and the amount and location of subarachnoid blood. They should document a 
proposed treatment plan based on the following options: 

•  endovascular coiling 
•  neurosurgical clipping 
•  no interventional procedure, with monitoring to check for clinical improvement and reassess 

the options for treatment.” 

We would strongly support that the pathways remain unchanged and given both complications and 
the original ruptured aneurysm if coiling is not feasible remain under the care of the neurosurgeons.  

We are happy to discuss this further with the Royal College of Surgeons and the Royal College of 
Radiologists if necessary. Once again, our sincere condolences to Mrs Ng’s family at this difficult time. 

 
 
 
 
 
 
 
 Yours sincerely, 

MBChB FRCP BSc (Hons) LLM 
Clinical Director for Patient Safety and Clinical Standards

From the President 

Dr Richard Brittain 
Assistant Coroner for the coroner area of Coventry 

29 January 2026 

Dear Dr Brittain 

Ref: 2025-0614 

Thank  you  for  your  “Man  Ng:  Prevention  of  Future  Deaths”  report  and  for  giving  the  RCS 
England the opportunity to respond.  

We were saddened to read the circumstances of Man Yin ‘Anita’ Ng death and we offer our 
sincere condolences to her family. 

Your  report  identified  concerns  in  relation  to  the  treatment  of  subarachnoid  haemorrhage 
(SAH) from an intracranial aneurysm, which occurred in the perioperative care of this patient. 
According to the report, the main circumstances of this event relate to the lack of prompt and 
definitive  treatment  of  aneurysms  to  prevent  rebleed  and,  most  critically,  the  lack  of  clear 
overall clinical responsibility of the patient’s care.  

Although we have no regulatory powers, the College provides advice and guidance to those 
who design surgical services and to the wider surgical care team for all aspects of surgical 
practice.  In  this  instance,  given  the  specialty-specific  nature  of  the  identified  issues,  we 
consulted with our colleagues at the Society of British Neurological Surgeons (SBNS) and at 
the British Neurovascular Group (BNVG).  

Evidence  suggests1,2  that  the  risk  of  aneurysm  rebleeding  is  highest  in  the  first  48  hours, 
making early and correctly prioritised treatment critical. At a system level, increased demand 
on neurointerventional infrastructure, particularly from expansion of mechanical thrombectomy 
services,  can  create  competition  for  catheter  laboratory  capacity,  specialist  staffing  and 
anaesthesia cover. In the absence of clear national guidance on prioritisation and clinical  
ownership, this has led to variation in practice, fragmented responsibility, and, in some cases, 
to  the  lack  of  prioritisation  and  delays  to  treatment  for  patients  with  ruptured  aneurysms, 

1 NICE (2022). Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. 
https://www.nice.org.uk/guidance/ng228  
2 AHA/ASA (2023). Guideline for the Management of Patients With Aneurysmal Subarachnoid Haemorrhage. 
https://www.ahajournals.org/doi/10.1161/STR.0000000000000436  
The Royal College of Surgeons of England 
38-43 Lincoln’s Inn Fields 
London WC2A 3PE 

T: 020 7869 6009 
E: president@rcseng.ac.uk 
W: www.rcseng.ac.uk                                                                                             Registered Charity No. 212808 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 increasing  the  risk  of  preventable  harm.  In  addition,  patients  receiving  care  from  different 
specialists often lack a clear advocate, particularly in units with lower emergency volumes.   

The  College  recognises  that  effective  decision-making  within  the  multi-disciplinary  team 
(MDT)  is  key  and  that  any  treatment  strategy  in  patients  with  aneurysmal  subarachnoid 
haemorrhage should be decided by teams with both surgical and endovascular expertise. The 
specific  details  of  how  this  service  should  be  delivered  by  the  MDT  may  vary  and  can  be 
decided locally provided there is sufficient input by both neurosurgeons and INR colleagues, 
leading to safe and effective treatment.  

However,  we  consider  that  neurosurgeons  are  best  positioned  to  manage  these  patients 
because they are trained to manage the full spectrum of SAH complications, including pre- 
and post-treatment challenges, regardless of whether the definitive intervention is surgical or 
endovascular. Neurosurgical team working patterns are also best placed to support continuity 
of care, which is crucial for these complex patients. 

Following this report, the College will work with the SBNS and BNVG to develop a position 
statement  setting  out  recommendations  for  the  management  of  the  clinical  care  of  SAH 
patients, and also for the provision of access to the recently published credentialling process 
for  thrombectomy  training  for  non-radiologists,  which  could  allow  neurosurgeons  with  a 
neurovascular interest to train in both endovascular and open surgical treatment to improve 
patient-centred decision-making. 

We hope that this response is clear and helpful and provides you with reassurance in relation 
to the serious consideration we have given to these matters and the actions we shall be taking 
in response.  

Yours sincerely 

 MA FRCS FDSRCS FRCP Edin FAIS(Hon) FCSSL(Hon) FSSN(Hon) 

President

Assistant Coroner R Brittain  
Manor House Drive 
Coventry 
CV1 2ND 

30/01/2026 

Dear Dr Brittain, 

RCR Response to Regulation 28: Prevention of Future Deaths report issued on 5 
December 2025 in relation to the death of Man Yin ‘Anita’ Ng. 

I was very sorry to read about the death of Man Yin ‘Anita’ Ng and I would like to express my 
deepest condolences to Anita’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 them 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. The RCR does not commission, fund, manage, or directly deliver clinical services. 
Responsibility for the organisation, resourcing, and operational delivery of emergency and 
specialist services lies with NHS providers, commissioners, and national bodies. However, 
the RCR has an important role in setting professional standards, providing guidance, 
supporting workforce development, and advocating for system-level change where patient 
safety and service sustainability are at risk. 

In preparing this response, we sought input from our specialty interest groups most closely 
aligned with this area of practice to ensure that our comments reflect the breadth of relevant 
expertise within the specialty. The British Society of Interventional Radiology feedback has 
been incorporated into the general observations set out below. 

We recognise and share your concerns regarding delays to investigation and treatment, 
variation in access to specialist neurointerventional procedures, and the challenges arising 
from fragmented clinical ownership across specialties. These issues reflect wider, 
longstanding system pressures within the NHS, including workforce shortages, constrained 
critical care and interventional capacity, and increasing demand for time-critical specialist 
radiological interventions. 

Your report highlights the complexity of care pathways where responsibility for admission and 
ongoing inpatient management may sit with one specialty, while definitive treatment is 
delivered by another. This model, which is common across Interventional Radiology (IR) can 
lead to ambiguity in clinical ownership, delays in decision-making, and difficulties in 
coordinating urgent care, particularly when services are under significant pressure. These 

 
 
 
 
 
 
 
 
 
 challenges are not confined to neurointerventional practice alone but are seen across 
multiple IR emergency and urgent care pathways, including vascular, hepatobiliary, and 
haemorrhage control services. As demand for minimally invasive, image-guided interventions 
has grown rapidly, the development of supporting infrastructure, workforce, and governance 
arrangements has not always kept pace. 

The RCR acknowledges the particular concern raised regarding the lack of admitting rights 
for interventional radiologists. Where interventional radiologists are responsible for delivering 
definitive, time-critical treatment but do not have admitting rights or direct access to inpatient 
beds, there can be a misalignment between procedural responsibility and overall clinical 
accountability. Evidence in the literature (T. Bryant, R. Ahmad, A. Diamantopoulos et al, 
2023)  has highlighted that admitting rights and involvement in ward-based care are 
important for patient safety, continuity of care, and the long-term sustainability of IR services. 
The RCR supports collaborative models that enable appropriate admitting rights and shared 
inpatient responsibility, tailored to local service configurations. 

We also recognise the pressures created by the rapid expansion of neurointerventional 
thrombectomy and aneurysm services over recent years. While these advances have 
delivered significant benefits for patients, their growth has often occurred in the context of 
limited workforce expansion and insufficient critical care, theatre, and interventional suite 
capacity. This has contributed to variability in service availability and resilience, particularly 
outside normal working hours. 

While the RCR cannot mandate service reconfiguration or staffing levels, we will continue to 
work with partner organisations, including specialist societies and national bodies, to 
advocate for sustainable workforce planning, clearer clinical governance arrangements, and 
equitable access to specialist interventional services. We will also continue to develop and 
update professional guidance and standards that support timely access to care and clarify 
roles and responsibilities within complex, multidisciplinary pathways. 

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 Anita’s family 
and loved ones. 

Yours sincerely, 

RCR President