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This is a story of a patient in whom the emergency department missed the same diagnosis twice, four years apart. The first occasion (prior to his diagnosis of ankylosing spondylitis) was understandable. The second was not. As a result of this case, the hospital have changed their x-ray policy for non-traumatic back pain. They also want to share key learning points (the majority of which were due to lack of awareness about a relatively rare condition and its complications) as widely as possible, to help others avoid the same errors.  This reflective learning features guest educator, Mr Gareth Dwyer (the patient).

There has been an increase in the number of units providing anaesthesia for magnetic resonance imaging and the strength of magnetic resonance scanners, as well as the number of interventions and operations performed within the magnetic resonance environment. More devices and implants are now magnetic resonance imaging conditional, allowing scans to be undertaken in patients for whom this was previously not possible. There has also been a revision in terminology relating to magnetic resonance safety of devices.  These guidelines, by the Association of Anaesthetists, have been put together by organisations who are involved in the pathways for patients needing magnetic resonance, reinforce the safety aspects of providing anaesthesia in the magnetic resonance environment and suggest that hospitals should develop and audit governance procedures to ensure that anaesthetists of all grades are competent to deliver anaesthesia in the magnetic resonance environment.

The objective of this investigation was to understand the context of magnetic resonance imaging (MRI) scanning under general anaesthetic and how care may be reasonably adjusted for patients with autism or learning disabilities. The ‘reference event’ was Alice, a teenage girl who had autism. Sadly, Alice died following her MRI scan under general anaesthetic. The findings and conclusions of this investigation may be applicable to other non-invasive procedures carried out on patients who are under general anaesthetic.