Recurring concern

Unreliable CTPA investigation and follow-up

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First reported 20 May 2014•Latest report 7 Mar 2022

Definition

What this concern includes

Includes failures of the CTPA process from requesting and communicating the procedure through completion, identification of missing procedures and timely follow-up or escalation.

Not included

Excludes failures concerning other diagnostic tests or scan modalities unless they are directly part of the same CTPA process.
Excludes generic communication, documentation or staffing deficiencies that are not specifically tied to CTPA investigation or follow-up.
Excludes clinical decisions about whether CTPA is the appropriate modality where no failure in CTPA completion or follow-up is identified.

Reports: 3
Individual concerns: 6
Date range: 2014–2022
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Blackpool Teaching Hospitals NHS Foundation Trust1

Frimley Health NHS Foundation Trust1

Frimley Park Hospital1

St George'S University Hospitals NHS Foundation 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.

7 Mar2022
Surrey
Concerns raised1
1. Failure to undertake second-line investigation of suspected perforation
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

ARTHUR FREDERICK HALL · 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

Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

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 undertake second-line investigation of suspected perforation
Wider context from the report
“3. Second line of enquiry (endoscopy or CTPA) was not undertaken. ”
Source location
ARTHUR FREDERICK HALL · Prevention of Future Deaths report
Page 4 · concerns
Open source report
22 May2015
Blackpool and the Fylde
Concerns raised4
1. Failure to complete urgent CTPA requests promptly
2. Failure of the clinical team to follow up missing CTPA procedures
3. Incorrect categorisation of urgent CTPA requests as outpatient requests
1. Failure to process urgent CTPA requests during holiday periods
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated planned
AI-generated summary

Olive Darbyshire · 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

Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.

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 complete urgent CTPA requests promptly
Wider context from the report
“1. Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, I am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place and that this had not happened some three days after the request was made. ”
Source location
Olive Darbyshire · Prevention of Future Deaths report
Page 2 · 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 of the clinical team to follow up missing CTPA procedures
Wider context from the report
“2. I am concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire's care making efforts to “chase up” the missing CTPA procedure. ”
Source location
Olive Darbyshire · Prevention of Future Deaths report
Page 2 · 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
Incorrect categorisation of urgent CTPA requests as outpatient requests
Wider context from the report
“3. I am concerned that the radiology department staff have incorrectly categorised Mrs Darbyshire in a way that meant that she spent a number of days in hospital awaiting an urgent CTPA procedure that in reality was not going to happen because once categorised as an outpatient she realistically would only expect to receive a CTPA in 2015 by way of a written notification. ”
Source location
Olive Darbyshire · Prevention of Future Deaths report
Page 2 · 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 process urgent CTPA requests during holiday periods
Wider context from the report
“4. I am concerned that given this request was made on 23rd December 2014, subsequent events have been influenced by the fact that the request was made shortly before the Christmas period and that a lack of action taken by the clinical team to “chase up” the CTPA and the actions of the radiology department administration staff have been influenced by reduced staffing levels over the Christmas holiday period when the department would deal with inpatient requests only, and emergency requests pertaining to Accident & Emergency patients. ”
Source location
Olive Darbyshire · 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
Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.

Verbatim wording from the response
“There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weaknesses regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.”

Source location
Olive-Darbyshire-Response
Page 2 · response
Published 22 May 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
Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.

Verbatim wording from the response
“This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.”

Source location
Olive-Darbyshire-Response
Page 2 · response
Published 22 May 2015
Open published response
20 May2014
Surrey
Concerns raised1
1. Failure of communication between junior doctors and radiologists causing delay in CTPA
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Rainer Wickens · 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

Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.

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 communication between junior doctors and radiologists causing delay in CTPA
Wider context from the report
“Breakdown in communication between junior doctor and radiologist resulting in avoidable delay of CTPA ”
Source location
Rainer Wickens · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to undertake second-line investigation of suspected perforation

Concerns raised4

Failure to complete urgent CTPA requests promptly

Failure of the clinical team to follow up missing CTPA procedures

Incorrect categorisation of urgent CTPA requests as outpatient requests

Failure to process urgent CTPA requests during holiday periods

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.2

Concerns raised1

Failure of communication between junior doctors and radiologists causing delay in CTPA

Actions described in response 2