Coroner urges review of staffing levels after tragedy

By by Adrian Darbyshire Twitter:@iomAdrian in Health

The Coroner is urging a review of staffing levels at the radiology department in Noble’s Hospital.

His recommendation was made following the inquest into the death of Glen Vine farmer Peter Quilliam.

Mr Quilliam, 70, died of a heart attack in September 2015 in the coronary care unit at Noble’s, just as he was about to be transferred by air ambulance to Liverpool.

The inquest heard he had suffered from a rare cardiac condition, dissection of the ascending aorta, which had gone undetected after his admission to hospital as it was not spotted by the radiologist who reviewed his CT scan.

Coroner John Needham delivered a verdict of natural causes, finding there was no gross failure amounting to neglect.

’I can find no support overall for an argument that Peter’s care generally amounted to a gross failure by the department,’ he said.

But the Coroner said lessons had to be learned.

The inquest heard that the radiology department at the time of Mr Quilliam’s death consisted of five consultant radiologists covered by one locum and four permanent consultants.

During the week of his admission to hospital, there was one person on annual leave and one person on study leave so there were three people covering the department. On two afternoons that week they were down to two consultant radiologists.

The upshot was that on the Friday there was only one radiologist dealing with all the requests. There may have been about 50 CT and 50 MRI scan requests to vet that morning, taking about two hours.

The consultant was also the on-call radiologist that day which meant she was fielding all of the questions and consultation requests.

She accepted she had not spotted the signs of the aortic dissection on the CT images and told the inquest that if she had maybe had a bit more information, or it been a different day of the week, or the department fully staffed she probably would have spotted the dissection.


The Coroner said if the aortic dissection had been spotted sooner, it may have improved the chances of Mr Quilliam surviving surgical treatment but he could not be confident to make a finding that he would have been saved.

But he said that had there been more radiology staff on duty on that day, lowering the consultant’s workload, there would have been a much better chance of the aortic dissection being picked up.

Mr Needham said he will report to the Minister of Health and Social Care to recommend a review into the resourcing of the radiology department with a view to there being more finances to recruit and retain sufficient consultant radiologists.