Recurring concern

Unreliable radiology processes for communicating findings and initiating required follow-up

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First reported 17 Oct 2014•Latest report 4 Mar 2026

Definition

What this concern includes

Includes failures in radiology processes for communicating clinically important findings or recommendations, confirming receipt by the responsible clinical team, enabling or initiating recommended additional investigations, and providing required radiologist reporting arrangements when these failures can delay diagnosis or follow-up care.

Not included

  • Excludes failures limited to interpretation of images where communication or follow-up is not deficient.
  • Excludes generic referral, appointment or investigation delays without a direct radiology finding, recommendation or reporting-process connection.
  • Excludes failures in the clinical management of a condition after the radiology finding and required follow-up have been reliably communicated and initiated.
  • Excludes generic information-system, staffing or commissioning deficiencies unless they directly impair the radiology communication or follow-up process.
  • Excludes the separate abdominal-aortic-aneurysm concern when the assertion is specifically about detection and management of that named condition rather than the radiology follow-up process itself.
Reports
16

Distinct published reports

Individual concerns
16

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
23

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.

Department of Health and Social Care3
Betsi Cadwaladr University LHB2
County Durham and Darlington NHS Foundation Trust2
NHS England2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Barts Health NHS Trust1
Homerton University Hospital1
Medica Reporting Services Limited1
Mersey Care NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
NHS Greater Manchester Integrated Care Board1
NHS Tower Hamlets Clinical Commissioning Group1
Royal College of Paediatrics and Child Health1
Royal College of Radiologists1
Royal London Hospital1

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. Lancashire and Blackburn with Darwen

    AI-generated summary

    Kristina CROSS · 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

    Kristina Cross, aged 72, was admitted on 28 August 2016 after an unwitnessed fall and was later found to have a displaced fracture of the neck of the femur. The fracture was initially misdiagnosed, delaying surgical fixation; she subsequently suffered wound complications and joint dislocations, deteriorated after further surgery, and died on 20 November 2016. The principal concerns were unfilled consultant radiologist posts and delays, or failures, in reporting radiological investigations needed for diagnosis and clinical decision-making.

    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 report non-urgent plain radiology unless specifically requested

    Wider context from the report

    “Evidence from the Lead Consultant Radiologist of the University Hospitals of Morecambe Bay NHS Foundation Trust was that whilst there was an initial misdiagnosis of the hip fracture there was a subsequent significant delay in reporting on plain radiology, due to a shortage of Consultant Radiologists. Furthermore evidence was heard that non-urgent plain radiology is not being reported at all unless specifically requested by clinicians. Evidence was heard that a quarter of positions within the Trust are currently unfilled. The Dalton Review of July 2014 identified that such is a national position, with comparatively low levels of radiologist training and retention with 41% of unfilled consultant radiological posts remaining unfilled for more than 12 months. In brief the concerns arising from the evidence are that a substantial number of consultant posts are unfilled, and that due to shortages of qualified radiologists, radiological investigations, crucial for diagnostic and clinical decision making purposes, are not reported on within the timescales set out within Professor Sir Bruce Keogh's report of 2013, or at all. ”

    Source location

    Kristina CROSS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Karen Ann Thorne · 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

    Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.

    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

    Delays in reporting neuroradiology and radiology

    Wider context from the report

    “1. During the Inquest evidence was heard that:- i. There are delays in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a delay of 60 days is still unacceptable. ii. There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists. iii. The delay in reporting radiology is of greater concern in cases where a patient is receiving treatment on a regular basis, namely every 28 days in the case of the Deceased, and the Scans are not reported for a period in excess of 60 working days, during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion. iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year and the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within a reasonable, necessary and expected time period. The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions. The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications. 2. I request you to consider the above concerns in relation to a national shortage of Radiologists and to review the number of training positions to address the national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment. ”

    Source location

    Karen Ann Thorne · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. North Wales (East and Central)

    AI-generated summary

    Mrs Mary Myfanwy Hollands · 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

    Mrs Mary Myfanwy Hollands, aged 98, sustained an unwitnessed fall at her nursing home and was later found to have a left hip bony injury that had not been identified on the initial X-ray. She deteriorated and died on 27 July 2015. The principal concern was that the system for conveying radiologists’ reports to the Emergency Department was not sufficiently reliable or safe, including failures in paper-report delivery and the lack of a prioritisation or coding system for reports identifying injuries.

    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

    Lack of a coding system to make injury-identifying radiologist reports easily identifiable for prioritisation

    Wider context from the report

    “(1) The system currently in place for radiologist’s reports being passed to the Emergency Department is not sufficiently reliable or safe so as to provide effective safety netting for patients. (2) Under the current system the x ray will be put on the PACS system and any obvious bony injury will have the words “red dot” typed on the area of the injury. The Emergency Department doctor must analyse all X-rays to check for an injury, whether or not marked with “red dot”. This is then followed with a radiologists report within 48 hours. The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes. The radiologist will in his report note any injuries which he has seen. This provides a safety net where an Emergency Department doctor may have missed a more subtle injury so that a patient, whom has been discharged can be recalled for future advice and/or treatment. (3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the busy Emergency Department can prioritise the reading of those reports with a view to recalling patients whose injuries have gone undetected. This is in the context of some 50000 patients passing through each Emergency Department each year, an average of one third of whom are x rayed . Time is currently being wasted in an already busy department ploughing through reports which do not need to be considered as no injury is disclosed. (4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when the paper report does not arrive, as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment, as in the case of Mrs Hollands. Once the paper report arrives in the Emergency Department the paper notes have to be located and the paper report attached before it can be considered in context. On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency (5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department, prioritising patient’s with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors. This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system. ”

    Source location

    Mrs Mary Myfanwy Hollands · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    A coding system for radiology findings would be difficult to develop because radiologists lack the patient’s full clinical care context.

    Verbatim wording from the response

    “Matters of concern paragraph 3. The suggestion is for a coding system to be in place. However, as the radiologists do not have the full clinical picture of the care given to the patient following their imaging it would be difficult to develop such a system.”

    Source location

    Mary-Hollands-Response
    Page 1 · response
    Published 21 December 2015

    Open published response

  4. Manchester West

    AI-generated summary

    Harry Pryal · 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

    Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

    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

    Lack of triage procedures for urgent or unexpected significant x-ray findings

    Wider context from the report

    “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines, although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay. WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination. An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay. ”

    Source location

    Harry Pryal · Prevention of Future Deaths report
    Page 4 · 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 and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.

    Verbatim wording from the response

    “A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway. This includes, and has started with the service level agreement for the provision of radiology services. The review process will incorporate the following steps:”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 2 · response
    Published 28 September 2015

    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

    Remind staff that Lakeside Unit patients must be treated as inpatients and update CRIS to reflect that status.

    Verbatim wording from the response

    “In the case of Mr Pryal, the x-rays undertaken by 5BP at Leigh Infirmary were treated the same as if he were based at an out-patient facility. It is acknowledged that there was a lack of understanding by health professionals at the Trust that Lakeside Unit is an inpatient facility. Mr Pryal’s x-rays should have been reviewed as if he was an inpatient, and then they would have been reported sooner.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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

    Provide weekday hot reporting of x-rays as soon as possible after examination.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Train reporting radiographers to interpret chest x-rays and expand specialist radiographer reporting capacity.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Hot reporting is not available at weekends because of resource constraints.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Local providers are responsible for reviewing local systems concerning X-ray reporting, electronic viewing and patient-note recording.

    Verbatim wording from the response

    “You outline the circumstances which led to this situation and direct several concerns to the 5 Boroughs Partnership NHS Foundation Trust (5BP) and Wrightington Wigan and Leigh NHS Foundation Trust (WWL) which relate to their joint Service Agreement, the reporting times for X-rays, the electronic systems available to support web viewing of X-rays and the recording of appropriate patient notes. These concerns are about the local systems that are in place and rightly addressed to the local providers, who I am confident will consider and review.”

    Source location

    2015-0391-Response-by-Department-of-Health
    Page 1 · response
    Published 28 September 2015

    Open published response

  5. Manchester South

    AI-generated summary

    HAROLD PENNY · 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

    HAROLD PENNY was admitted to hospital on 12 June 2014 and died on 20 June after investigations found a grossly distended bladder and a misplaced urinary catheter. The principal concern was that there was no system requiring radiology staff to rectify such problems where possible or urgently report them to treating clinicians.

    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 require radiology to urgently report findings to treating clinicians

    Wider context from the report

    “There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible, nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage. ”

    Source location

    HAROLD PENNY · Prevention of Future Deaths report
    Page 1 · 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

    Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.

    Verbatim wording from the response

    “Work is being undertaken in this area at the Trust as part of the Sign up to Safety campaign which was launched by the Secretary of State for Health on 24 June 2014 with a mission to strengthen patient safety in the NHS. A draft ‘Radiology Requesting and Reporting Policy’ has been produced by the Trust and is currently going through our governance procedures.”

    Source location

    2014-0507-Response-by-Tameside-Hospital-NHS-Trust
    Page 1 · response
    Published 24 November 2014

    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

    Operate the Results Governance Steering Group to implement and continuously improve results-governance processes, with monthly meetings.

    Verbatim wording from the response

    “A Results Governance Steering Group (RGSG) was also developed in October 2013 and is one of ten project teams that report to the Tameside Hospital Patient Safety Programme Board (PSPB) as part of the ‘Keeping patients safe and reducing harm’ programme. The RGSG met for the first time on 4 November 2014 and is concerned with ensuring that the Trust has clinical and operational processes to adequately support effective results governance. The scope of this group is to ensure that effective results governance processes are in place to timely recognition and escalation of abnormal clinical results. The 2014-2015 objectives of this group specifically include improving the standards of results governance from both a report and service delivery perspective. The group has completed an initial review of processes and is now meeting monthly to ensure implementation and continuous improvement.”

    Source location

    2014-0507-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    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 Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.

    Verbatim wording from the response

    “Department examinations the same day. Where there are urgent findings (where medical evaluation is needed within 24 hours) the expectation will be that these are reported within four hours, the time frame depending on the nature of the imaging findings. Priority is given to inpatients, urgent requests and unexpected significant findings. The Trust’s objective is to document significant radiological findings and ensure they are communicated in a timely and unequivocal fashion. The Trust is reviewing its IT infrastructure to ensure this support is in place.”

    Source location

    2014-0507-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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 frameworks for tracking and following up all radiology reports and ensure they are robust.

    Verbatim wording from the response

    “As set out above, the policy that we are in the process of ratifying, places a great deal of responsibility with the Radiologists within the Trust. However, it is important to note the responsibilities of the referring clinicians also. It is their responsibility to ensure that they have in place a robust system to enable tracking and follow up of all radiology reports. One of the focus areas of the RGSG is to review frameworks for tracking and follow up of all radiology reports and ensure these are robust. Once received, reports should be legibly signed, dated and filed in a permanent patient record with a clear indication of any action taken following receipt of the report. It is the responsibility of the referring clinician to ensure this takes place and individual systems in place will be subject to regular audit.”

    Source location

    2014-0507-Response-by-Tameside-Hospital-NHS-Trust
    Page 4 · response
    Published 24 November 2014

    Open published response

  6. Inner North London

    AI-generated summary

    Stephen Atherton · 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

    Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

    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

    Delays in radiologist-recommended additional investigations when GPs cannot request them

    Wider context from the report

    “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays. This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations. This is particularly the case where the suggested investigations cannot actually be requested by GPs. The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case. ”

    Source location

    Stephen Atherton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026