Recurring concern

Failure to ensure diagnostic images are stored and available for safe clinical review

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First reported 21 Jun 2019•Latest report 6 Jun 2025

Definition

What this concern includes

Includes failures to store, retain, retrieve, display or otherwise make clinically important diagnostic images available to the clinicians responsible for safe assessment, review or treatment, including failures involving PACS or comparable image systems and failures that leave images unavailable for subsequent examination.

Not included

  • Excludes failures limited to the interpretation or clinical quality of images when the images were reliably stored and available.
  • Excludes failures to communicate or act on an imaging finding after the relevant images were reliably available, unless image availability was also deficient.
  • Excludes delays in requesting or performing imaging where the images were not yet acquired and storage or availability was not the unsafe condition.
  • Excludes generic electronic-record, IT or radiology-service deficiencies without a direct diagnostic-image storage or availability failure.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2019–2025

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Calderdale and Huddersfield NHS Foundation Trust1
Department of Health and Social Care1
Leeds Teaching Hospitals NHS Trust1
NHS Greater Manchester Integrated Care Board1
NHS Kent and Medway Integrated Care Board1
Pennine Acute Hospitals NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Esme Vera Louise Atkinson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to store cardiac images from abnormality scans

    Wider context from the report

    “6. Esme had the usual abnormality scan which the inquest was told did not detect the defect on her heart. The inquest was told that the cardiac part of the abnormality scan was not audited in England under national guidance and the cardiac images were not stored. This meant they were not available for subsequent examination. ”

    Source location

    Esme Vera Louise Atkinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review whether national guidance should require archiving fetal cardiac views from 20-week screening scans.

    Verbatim wording from the response

    “Your report also flagged that the cardiac part of an abnormality scan is not audited in England under national guidance and cardiac images are not stored, meaning they are not available for subsequent examination. Currently there is no NHS FASP requirement to archive images of the fetal cardiac protocol. We acknowledge your concern and NHS England are currently reviewing this and, if required, will revise current guidance on the storage of cardiac views at the 20-week screening scan.”

    Source location

    Response from Department of Health and Social Care
    Page 4 · response
    Published 18 June 2025

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    Kerri Louise Mothersole · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kerri Louise Mothersole, a 44-year-old woman, died on 20 August 2022 after developing endometrial cancer with brain metastases. Her diagnosis was delayed, including because an earlier ultrasound report and associated images were not provided to treating clinicians or uploaded to hospital clinical notes, and community imaging was not available on the central imaging system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make private-provider imaging available through the central imaging system

    Wider context from the report

    “(1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage. (2) The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance. (3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths. ”

    Source location

    Kerri Louise Mothersole · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide community ultrasound reports and images to treating clinicians

    Wider context from the report

    “(1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage. (2) The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance. (3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths. ”

    Source location

    Kerri Louise Mothersole · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue transitioning providers from individual PACS systems to a central PACS system, including integration of acute provider trusts.

    Verbatim wording from the response

    “To address the concerns highlighted in the Regulation 28 Report, we can confirm that Kent and Medway have been moving away from individual PACS systems resident in each of our providers to a central PACS system. Procurement commenced in 2021, with the integration of acute provider trusts in September 2023.”

    Source location

    Response from Kent and Medway
    Page 2 · response
    Published 14 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the incident and diagnostic workflow, audit data-sharing systems, and produce and assess an options appraisal for process and IT integration improvements.

    Verbatim wording from the response

    “2. To provide longer term assurance, and in acknowledgment of this matter, NHS Kent and Medway will examine potential changes where appropriate relating to IT integration. To support this, we will undertake a review of how the incident occurred and determine how the risk of this re-occurring can be reduced. This will include:”

    Source location

    Response from Kent and Medway
    Page 3 · response
    Published 14 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    GPs receive community diagnostic reports, assess them clinically, and decide whether referral to secondary care is required.

    Verbatim wording from the response

    “Community diagnostics were introduced in the 2010s to improve access and reduce cost. However, no work was commissioned at the time to provide integration to GP or acute systems. The standard protocol is for community diagnostic providers to send reports (text-based), as opposed to the full diagnostics image, back to the GP that requested the investigation. The GP will then assess the report in the context of their holistic assessment of the patient and they make a clinical decision on whether to refer a patient to secondary care.”

    Source location

    Response from Kent and Medway
    Page 2 · response
    Published 14 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The first ultrasound report was inaccurate and should not have been sent to the patient’s GP.

    Verbatim wording from the response

    “For information regarding this patient’s case, the ICB Patient Safety Team has requested that HEM Clinical Ultrasound complete a Serious Incident (SI) Investigation regarding the Coroner’s first concern. This concern notes that there were two ultrasound reports available, only one of which was initially sent to the patient’s GP. The provider has stated that that first report was inaccurate and should not have been sent to the patient’s GP.”

    Source location

    Response from Kent and Medway
    Page 2 · response
    Published 14 March 2024

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    Sharon Jamela Reeve · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Slow image-transfer conduit preventing review of CT and MRI images

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester North

    AI-generated summary

    Deborah Anne Hopkinson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Deborah Anne Hopkinson was treated for Cushing’s disease caused by a pituitary adenoma and later developed pneumocystis pneumonia. Her condition deteriorated during intensive care, and she died at Fairfield General Hospital on 26 September 2018 after a cardiac arrest. Concerns included equipment failures, delays in specialist advice and delays in recognising and treating complications associated with Cushing’s disease.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the PACS system to provide access to MRI scans

    Wider context from the report

    “1. The inquiry heard that there were numerous occasions when equipment failure occurred and this is likely to have had some impact on the treatment which the deceased received i. When the deceased was re-admitted to hospital on 12 September 2018 there was delay of some 6 days in involving the endocrine consultant at Fairfield Hospital and the reason given during the inquiry was that the computer system was down. ii. The inquiry heard the importance about controlling the cortisol levels yet there was evidence to the effect that the analyser for running the cortisol sample was down multiple times during the deceased’s admission. iii. There was a significant deterioration in the deceased’s condition in the evening of 25 September 2018 but a CT abdomen could not be performed because the CT scanner at Fairfield Hospital was not working. iv. When the deceased’s was discussed at an MDT meeting on 13 September 2018 the MRI scan could not be viewed on the PACS system. ”

    Source location

    Deborah Anne Hopkinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026