First reported 7 May 2015•Latest report 25 Sep 2025
Definition
What this concern includes
Includes failures of controls specifically intended to establish or verify patient identity during healthcare contacts, including treatment encounters, telephone or SPA contacts, use of identifying information, searches, and positive identity checks.
Not included
Excludes identity or contact-detail failures outside healthcare provision unless they directly affect identification of a patient for healthcare.
Excludes generic staff training, documentation, communication or information-system deficiencies unless they directly impair patient identification.
Excludes failures involving identification of clinicians, relatives, carers, premises, callers or other non-patient subjects.
Excludes downstream treatment, prescribing or record-matching errors where patient identification was not itself deficient.
Reports
7
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
17
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.
Central and North West London NHS Foundation Trust1
Metropolitan Police Service1
NHS England1
Nottingham University Hospitals NHS Trust1
Tameside and Glossop Integrated Care NHS Foundation Trust1
the Rotherham NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1
Warwickshire Police1
York and Scarborough Teaching Hospitals NHS Foundation Trust1
NHS trust6
Police force2
Executive non-departmental public body1
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.
North Yorkshire and York
Concerns raised3
Failure to positively identify patients during treatment encounters
Continuing risk from patient misidentification
Failure to positively identify patients before radiology transfer and CT scanning
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Review the patient identification policy and strengthen adherence using learning from the case.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Communicate Trust-wide reminders to staff about the importance of positive patient identification.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Audit compliance with the patient identification policy regularly.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Complete development and governance review of a standardised checklist for all radiological transfers.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2025.
Action
Obtain approval, publish and deploy the standardised radiology transfer checklist for use.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Empower radiographers to decline radiological investigations when the transfer checklist is incomplete.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Monitor checklist compliance through Radiology clinical governance meetings and escalate issues to the Care Group Board.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Inner West London
Concerns raised1
Insufficient training of SPA call handlers in patient identification and information seeking
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Provide SPA call handlers with induction guidance, phonetic-alphabet prompts and a minimum-question checklist for identifying patients and callers.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Provide recruit officers with phonetic-alphabet training through handouts, simulated radio transmissions and Street Duties role-play practice.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Amend the airwave-etiquette handout to emphasise using the phonetic alphabet for name checks.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing MPS provision is considered sufficient to meet the phonetic-alphabet learning need for new recruits.
Stated by Metropolitan Police ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Warwickshire
Concerns raised1
Failure to identify unconscious patients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Issue organisation-wide learning requiring hospital enquiries to identify unknown patients, linked incidents to be researched, and fingerprints to be considered where medically relevant.
Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 25 January 2022.
South Yorkshire (Eastern)
Concerns raised1
Absence of an effective system to identify patients under the care of departing staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Develop and assess an improved patient-allocation system for staff absences, including a flow chart, interim oversight, risk assessment and RAG prioritisation.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2017.
Manchester South
Concerns raised1
Failure to verify inpatient identity before transfer to radiology
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Failure to ensure that x-rays are performed for the patient for whom they are intended
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Strengthen induction training for new doctors on avoiding multiple open patient pages in the Notis system.
Stated by Nottingham University HospitalStated completedThe respondent said that this action was complete when they made their response on 11 May 2015.
Action
Update radiography checking procedures to assess clinical details and manage discrepancies.
Stated by Nottingham University HospitalStated completedThe respondent said that this action was complete when they made their response on 11 May 2015.
Action
Operate an established system for reporting and investigating recognised ionising-radiation incidents, including routine root-cause analysis of incorrect imaging referrals.
Stated by Nottingham University HospitalStated completedThe respondent said that this action was complete when they made their response on 11 May 2015.
Action
Consider introducing stronger technological barriers, including a patient photograph, to prevent incorrect patient selection in Notis.
Stated by Nottingham University HospitalStated plannedThe respondent said that this action was planned when they made their response on 11 May 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No technological safeguard for incorrect patient selection was implemented because potential barriers were considered capable of creating other patient safety concerns.
Stated by Nottingham University HospitalUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Brighton and Hove
Concerns raised1
Failure to provide patient identity wristbands
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls specifically intended to establish or verify patient identity during healthcare contacts, including treatment encounters, telephone or SPA contacts, use of identifying information, searches, and positive identity checks.
