First reported 14 Oct 2013•Latest report 31 Mar 2026
Definition
What this concern includes
Includes failures of the diagnostic imaging interpretation process, including incorrect interpretation or failure to recognise abnormalities on X-rays, CT scans and comparable diagnostic images.
Not included
Excludes delays in radiological reporting or specialist review where the concern is timeliness rather than interpretation.
Excludes inappropriate reliance on a diagnostic modality's known limitations unless the concern is specifically the failure to account for those limitations.
Excludes failures in clinical examination, communication, documentation or treatment that are not directly a failure to interpret diagnostic imaging.
Reports
17
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
43
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.
Barking, Havering and Redbridge University Hospitals NHS Trust3
NHS England3
Department of Health and Social Care2
Care Quality Commission1
Epsom and St Helier University Hospitals NHS Trust1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Liverpool Heart and Chest Hospital1
Liverpool Heart and Chest Hospital NHS Foundation Trust1
Medica Reporting Limited1
Mid Yorkshire Teaching NHS Trust1
Office of the Chief Coroner1
Queen's Hospital, Romford1
Royal College of Anaesthetists1
Royal College of Emergency Medicine1
NHS trust9
Healthcare site6
Executive non-departmental public body3
Health professional body2
Ministerial department2
Multi-service care provider2
Private limited company2
Coronial office1
Health and social care service regulator1
Registered charity1
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.
West Yorkshire Western
Concerns raised1
Lack of paediatric radiology expertise in out-of-hours imaging interpretation
This report raised 4 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.10
Action
Reinforce clinician-to-radiologist communication processes for complex cases and maintain audit and peer review of radiology reports.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Roster a senior radiologist on every emergency shift for immediate peer consultation, second opinions, clinical discussion, and escalation support.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Encourage structured standard reports for CT head examinations to support systematic assessment of key infant imaging features.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Conduct retrospective senior-consultant second readings of all paediatric CT examinations within the same shift and monitor capacity constraints.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Provide prospective double reading for all paediatric CT scans involving children aged 0–5 years.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Share governance learning within the Emergency Radiology service on infant CT limitations and explicit escalation advice.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Increase prospective second reading for high-risk paediatric CT brain examinations, particularly for specified under-five neurological, infection, or safeguarding presentations.
Stated by Telemedicine Clinic LimitedStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.
Action
Engage the client about service needs and discuss whether introducing or expanding prospective double reading would benefit its service.
Stated by Telemedicine Clinic LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
Action
Formally recognise scope-of-practice limitations and encourage radiologists to state when subspecialist review or further imaging is recommended.
Stated by Telemedicine Clinic LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Review the effectiveness of second-reading processes and escalation pathways during 2026 and report findings through clinical governance.
Stated by Telemedicine Clinic LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Routine overnight access to subspecialist paediatric radiology reporting is unavailable within West Yorkshire.
Stated by Mid Yorkshire Teaching NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
General consultant radiologists supported by governance and escalation safeguards are considered appropriate; complete elimination of paediatric imaging risk is not expected.
Stated by Telemedicine Clinic LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to report abnormal abdominal vascular findings on CT scans
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.4
Action
Introduce a SEIPS-based discrepancy-learning project, including rapid reviews and dual-track PSIRF systems-thinking investigations.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2025.
Action
Introduce Radiology peer review aligned with RCR guidance, scaling monthly case reviews and reporting learning through governance dashboards.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2025.
Action
Deliver a grand round teaching session on acute and chronic presentations of mesenteric arterial occlusion.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2025.
Action
Replicate the plain-film peer-review standard operating procedure across other Radiology modalities and specialties.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2025.
Sunderland
Concerns raised1
Failure to ensure interpretation of the whole scan
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
Share identified radiology learning with Trust radiologists, emphasising search extent, confirmation bias and comparison of relevant prior imaging.
Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
West Yorkshire (Western)
Concerns raised1
Failure to recognise and report slipped gastric bands on imaging
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.2
Action
Ask the relevant editor to consider the case theme and signpost a suitable anonymised CT case for educational material.
Stated by Royal College of RadiologistsStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
Action
Issue a Patient Safety Update notifying Trusts about national recommendations for imaging alerts and notifications.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Emergency imaging cannot currently be reported by locally based subspecialists in every case because NHS staffing and IT provision make this impossible.
Stated by Royal College of RadiologistsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Gastric-band slippage alone is not necessarily a surgical emergency, and recognising it may not have changed the outcome within the available timeframe.
Stated by Royal College of RadiologistsDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Emergency out-of-hours CT reporting is generally a core competency that can be delivered by radiologists without the relevant subspecialist interest.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS Trusts outsourcing imaging reports remain responsible for patients and must govern teleradiology providers through robust contractual arrangements.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The external reporting provider is responsible for undertaking its own investigation into discrepancies in the radiological reporting.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure to account for the limited sensitivity of upright chest X-rays when excluding 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.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to correctly interpret scans
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.
East London
Concerns raised1
Failure to recognise abnormal findings on abdominal radiographs
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.2
Action
Develop a guideline with Radiology and General Surgery to replace plain abdominal radiographs with CT for specified acute abdominal presentations.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Provide weekly virtual teaching on radiographic assessment and related diagnostic issues.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Manchester South
Concerns raised1
Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
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.9
Action
Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Share learning from this case with reporting radiologists.
Stated by Medica Reporting LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.
Stated by Medica Reporting LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.
Stated by Medica Reporting LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The reporter normally uses MPR tools, so the concern that their use was not assured is disputed.
Stated by Medica Reporting LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing MPR training, guidance, auditing, refresher training and shared learning address MPR use in CT reporting.
Stated by Medica Reporting LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
MPR tool use cannot be monitored or measured in a simple or meaningful way.
Stated by Medica Reporting LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure by Consultant Radiologists to identify clear and obvious neck fractures on CT scans
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.2
Action
Include the case in mandatory neuroradiological training for all radiology specialist registrars.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Action
Discuss learning from the case with all radiologists through scheduled Radiology Events and Learning Meetings.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Manchester South
Concerns raised1
Failure of imaging review processes to identify fractures
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.4
Action
Implement peer review for Advanced Practitioner Radiographers and Radiologists using a consistent reporting-review process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
Action
Conduct weekly random audits of reporting, including additional chest and abdominal examinations, with discrepancy arbitration and feedback.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
Action
Require preceptorship, supervised double reporting, accuracy assessment and remedial development before newly qualified reporting radiographers practise independently.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
Action
Hold monthly Radiology Event and Learning Meetings to discuss reporting discrepancies and support departmental learning.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The rib fractures were obscured by extensive pleural effusion and were unlikely to have altered treatment or contributed to death.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The team requesting diagnostic imaging is responsible for reviewing it to inform ongoing care and clinical management.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing peer review, audit, discrepancy arbitration, feedback and learning arrangements provide the Trust’s response to radiology reporting errors.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of the diagnostic imaging interpretation process, including incorrect interpretation or failure to recognise abnormalities on X-rays, CT scans and comparable diagnostic images.
