See Something, Say Something: the coroner's perspective

Kristal Lee, Kriscia Tapia, Mo'ayyad Suleiman, Catherine Jones, Patrick C. Brennan, Ernest Ekpo

Research output: Contribution to journalMeeting Abstractpeer-review


The Medical Radiation Practice Board of Australia’s ‘Communicating safely’ policy,1 also known as See Something, Say Something, outlines that if a medical radiation practitioner identifies urgent or unexpected findings, they must communicate this information in a timely manner to the appropriate healthcare practitioner.
This policy was born from coronial inquiries involving the untimely death of patients due to errors or result delays in medical imaging. Recommendations from the coroner in 20132 were for skilled radiographers to alert medical staff to a ‘clear and significant issue relating to patient safety.’ This was then highlighted again by another untimely and avoidable death – this time of a child – in 2015 where the coroner3 reiterated the need for early clinical notification of significant findings by radiographers. In 2017, radiographers were again reminded by the coroner4 that unexpected, urgent, or sinister radiological findings should be the subject of immediate communication to the referring medical practitioner. This was also in relation to an avoidable death.
The aim of this work is to present the historical coronial inquiries of three patients, and the coroners’ subsequent recommendations that are reflected in the See Something, Say Something capabilities. As medical radiation practitioners gain a greater understanding of the origin of these professional capabilities, they will be able to better meet their present requirements. This will empower medical radiation science practitioners to shape the future of the profession and improve patient safety through the ongoing enactment of the See Something, Say Something framework in clinical practice.

1.Medical Radiation Practice Board of Australia (MRPBA). Policy: Communicating safely – if urgent or unexpected findings are identified. 2019.
2.State Coroner’s Court. Findings of Inquest: Verna Therese Hamilton. 2013.
3.State Coroner’s Court. Findings of Inquest: Summer Alice Steer. 2015.
4.State Coroner’s Court. Findings of Inquest: MAYELL Edward John. 2017.
Original languageEnglish
Pages (from-to)80
Number of pages1
JournalJournal of Medical Radiation Sciences
Issue numberS1
Publication statusPublished - Apr 2023
EventAnnual Scientific Meeting of Medical Imaging and Radiation Therapy 2023 - International Convention Centre, Sydney, Australia
Duration: 27 Apr 202330 Apr 2023 (Oral Abstracts) (Poster Abstracts) (Author Index)

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