Recurring concern

Unreliable interpretation of diagnostic imaging

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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

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. Brighton and Hove

    AI-generated summary

    Mrs Frances Jean Gibb · 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 Frances Jean Gibb died in circumstances considered at an inquest, which concluded with a narrative conclusion. The concerns identified were serious failings in the use of NEWS and a failure to identify a mesenteric thrombus, apparently while a junior radiologist was working overnight under pressure.

    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 identify mesenteric thrombi in overnight radiology practice

    Wider context from the report

    “(2) There was a failure to identify a mesenteric thrombus (see Record of Inquest) This appears to have occurred when the junior radiologist was working overnight and under pressures. What lessons have been learned from this? ”

    Source location

    Mrs Frances Jean Gibb · 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

    Remind radiologists and trainees to specifically assess the superior mesenteric artery when investigating suspected ischaemic bowel.

    Verbatim wording from the response

    “1. All Radiologists including trainees have been reminded to look specifically at the SMA when the request is for a queried ischemic bowel.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 3 · response
    Published 30 December 2019

    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

    Change radiology protocols to use thinner two-plane reconstructions for improved regional visualisation.

    Verbatim wording from the response

    “2. The Protocol has changed so the reconstructions are thinner in two planes to enable better visualisation of the region.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 3 · response
    Published 30 December 2019

    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

    Require next-morning Consultant review of overnight scans reported by pre-FRCR Part 2b trainees.

    Verbatim wording from the response

    “3. All overnight scans are reviewed by a Consultant the following morning for those reported by pre Fellowship of the Royal College of Radiologists (FRCR) Part 2b trainees overnight.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 3 · response
    Published 30 December 2019

    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

    Enable discretionary next-morning Consultant review of scans reported overnight by post-FRCR Part 2b trainees.

    Verbatim wording from the response

    “4. Any scans reported by post FRCR Part 2b trainees can be reviewed the following morning by a Consultant at the trainee's discretion.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 3 · response
    Published 30 December 2019

    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

    Re-present the case through the REAL radiology learning and case-review meeting.

    Verbatim wording from the response

    “5. Mrs Gibb’s case has been re-presented in our REAL (Radiology Events and Learning through case review) meeting.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 3 · response
    Published 30 December 2019

    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 missed embolus was difficult to diagnose, perception errors can occur, and no particular reporting pressure, interruption or distraction was identified.

    Verbatim wording from the response

    “Radiology As confirmed in ████████ statement for the inquest, the initial CT report missed an embolus lodged in the superior mesenteric artery which was not causing radiological bowel changes at the time. ████████ confirmed that this was not an easy diagnosis to make and, having shown the scans to some of his Consultant Radiological colleagues, not all of them identified the embolus on the imaging. As acknowledged by ████████ in his statement for the inquest, perception errors such as these unfortunately do occur in the field of radiology and any misses are discussed by the team in regular discrepancy meetings. ████████ did not state that he was under any particular pressure when he reported Mrs Gibb’s scan, and he could not recall any particular interruption or distraction that night.”

    Source location

    2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
    Page 2 · response
    Published 30 December 2019

    Open published response
  2. Cambridgeshire and Peterborough

    AI-generated summary

    Sam Antony Crick · 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

    Sam Antony Crick, aged 24, developed recurrent hydrocephalus and progressively raised intracranial pressure before a catastrophic collapse on 29 February 2016. He underwent emergency neurosurgical intervention but died at Addenbrookes Hospital on 4 March 2016. The concerns included missed radiological and ophthalmological signs of rising intracranial pressure, delays in obtaining and considering important imaging information, and the absence of a serious incident investigation.

    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 neuroradiological review to identify and flag critical intracranial pressure indicators

    Wider context from the report

    “(B). The neuroradiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the pre-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure. Furthermore, there is now a separate investigation on the death of another person (SP) where involvement of the neuroradiology department at the Queens hospital is a central issue. ”

    Source location

    Sam Antony Crick · 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

    Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.

    Verbatim wording from the response

    “The Consultant Neurosurgeon involved in these examinations is no longer practicing in the Trust and is therefore unable to personally comment. These failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen again.”

    Source location

    2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 25 August 2017

    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

    Make recommendations to prevent recurrence of the identified examination and specialist-advice failures.

    Verbatim wording from the response

    “The Consultant Neurosurgeon involved in these examinations is no longer practicing in the Trust and is therefore unable to personally comment. These failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen again.”

    Source location

    2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 25 August 2017

    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 Trust disputes that the missed brain herniation finding was obvious, stating that this was an exceptionally rare complication.

    Verbatim wording from the response

    “The neuro-radiological review of the CT scans in November 2015 and early December 2015 did not highlight the brain parenchymal herniation through the re-existing burr hole as this finding was missed. This is an exceptionally rare complication; the Neuro-radiologist who reported the scan and who has 17 years of experience as a Consultant Neuro-radiologist has never previously encountered this complication. The Trust acknowledges this finding was missed by the reporting Neuro-radiologist but does not accept that the finding was ‘obvious’ as suggested.”

    Source location

    2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 25 August 2017

    Open published response
  3. Black Country

    AI-generated summary

    Dorothy Webb · 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

    Dorothy Webb’s health declined amid falls, suspected neurological events, hyponatraemia and subsequently identified small cell carcinoma of the right lung with liver metastases. She died shortly after aspirating vomited blood and gastric contents following episodes of coffee-ground vomiting. The report identified a missed opportunity to assess a CT scan showing a mass and a failure to note a fracture on an earlier x-ray.

    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 note fractures on X-rays during admission

    Wider context from the report

    “2. There was also a failure to note a fracture from the x-ray during the admission in February 2017 and consequently the patient and family were unaware of its existence until the re-admission in April 2017. ”

    Source location

    Dorothy Webb · 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

    Establish individual Consultant Radiologists’ error and discrepancy-rate monitoring to identify practice and training needs.

    Verbatim wording from the response

    “• To ensure the system for imaging discrepancy and error rate monitoring is robust to assure that individual errors in reporting are monitored to ensure they are in accordance with Royal College guidelines and identify individual training issues which require further support we have established individual Consultant Radiologists error and discrepancy monitoring rate to highlight practice issues and where training and development is required.”

    Source location

    2017-0273-Response
    Page 3 · response
    Published 25 November 2017

    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 additional training to reporters on the differing CRIS and PACS image presentation order.

    Verbatim wording from the response

    “• The CRIS and PACS records presented in a different order – CRIS (the Radiologist’s reporting system) shows the images in newest to oldest order while PACS (the system that holds the images) shows in the oldest to newest order. The PACS manager investigated whether the system could be configured to reverse the order of image presentation to match CRIS. It cannot so additional training has been provided to all reporters.”

    Source location

    2017-0273-Response
    Page 3 · response
    Published 25 November 2017

    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 individual radiologist’s error rate was below the threshold requiring remedial action, so no remedial intervention was considered necessary.

    Verbatim wording from the response

    “• A review of the individual’s practice was undertaken and the error rate was below that which requires remedial action.”

    Source location

    2017-0273-Response
    Page 3 · response
    Published 25 November 2017

    Open published response
  4. Inner North London

    AI-generated summary

    Lita SERKES · 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

    Lita Serkes underwent surgery at Whipps Cross Hospital on 22 July 2016, suffered a stroke the following morning, was transferred to the Royal London Hospital later that day, and died on 24 July. The concerns included discrepancies in observations and clinical records, delay in transfer for specialist stroke care, undelivered pain relief, and delayed recognition and assessment of a significant bleed.

    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 recognise the limitations of imaging in assessing active bleeding

    Wider context from the report

    “6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre. However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active. When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day. After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital. He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated. He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that. ”

    Source location

    Lita SERKES · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. Bedfordshire and Luton

    AI-generated summary

    Nicola Valerie MARSDEN · 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

    Nicola Valerie MARSDEN developed neurological symptoms before and after giving birth by Caesarean Section at Bedford Hospital on 14 November 2012. An MRI scan was mis-interpreted, and her condition was not recognised as a haemorrhagic infarct; she died on 17 November 2012 from raised intracranial pressure due to a cerebral haemorrhage. The concern was that neurological and brain scans were interpreted by a Radiologist rather than a Neuro-Radiologist, despite a guideline for specialist review.

    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 ensure neurological and brain scans are viewed and reported by Neuro-Radiologists

    Wider context from the report

    “• That during the course of the evidence I was told that the brain scan relating to the deceased was mis-interpreted. The CT scans were viewed by a Radiologist and not a Neuro-Radiologist, despite the fact that there is a Guideline for having the scans viewed by a Neuro-Radiologist at Addenbrooke’s Hospital. • My concern is that the interpretation of neurological scans and brain scans should be viewed and reported by Neuro-Radiologists and perhaps the Protocol for viewing of scans by non-specialists should be reviewed. ”

    Source location

    Nicola Valerie MARSDEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Avon

    AI-generated summary

    Gerald Trevor WERRETT · 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

    Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.

    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

    Incorrect interpretation of the cardiac silhouette

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

    Source location

    Gerald Trevor WERRETT · 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

    Misinterpretation of chest x-rays

    Wider context from the report

    “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

    Source location

    Gerald Trevor WERRETT · 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

    Local services should review the environment, clinician training, ultrasound availability and rapid reporting arrangements.

    Verbatim wording from the response

    “Following this incident, the key things we feel that should be reviewed locally are whether the environment supports the review of X-rays (e.g. availability of IT in the room where the procedure was carried out), if the doctor was trained in the use of ultrasound guidance for insertion of chest drains and whether ultrasound was available, in addition to the availability of rapid 24 hour reporting.”

    Source location

    2014-0355-Response-by-The-College-of-Emergency-Medicine
    Page 1 · response
    Published 1 August 2014

    Open published response
  7. Surrey

    AI-generated summary

    Frederick Davidson · 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

    Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.

    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 recognise pneumothorax on X-rays

    Wider context from the report

    “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. • The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures • Unexplained and important gaps in the clinical notes • Breakdown in communication between the junior doctor and consultant. • The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. • The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. • Delay in the forwarding and receipt of x ray reports from radiology ”

    Source location

    Frederick Davidson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026