Recurring concern

Unreliable X-ray request and progression processes

First to latest report 21 Aug 2014 — 24 May 2022

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
5

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable X-ray request and progression processes’ and satisfy this evidence boundary: Both distinct reports directly concern X-ray requests that were rejected, not properly made or not progressed promptly. No direct cross-report support establishes CT or diagnostic imaging generally, so preserve the specific X-ray object.

What is not included
  • Excludes delays in performing or reporting imaging after a request has been reliably accepted and progressed.
  • Excludes failures limited to interpreting or acting on imaging findings after the imaging process has operated reliably.
  • Excludes generic clinical training, communication or documentation deficiencies unless they directly impair diagnostic-imaging request or escalation processes.
  • Excludes condition-specific imaging pathways where a narrower named concern provides the more specific supported boundary.
  • Excludes manifestations outside the manually reviewed boundary: Both distinct reports directly concern X-ray requests that were rejected, not properly made or not progressed promptly. No direct cross-report support establishes CT or diagnostic imaging generally, so preserve the specific X-ray object.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    Michael Nestor WYSOCKYJY · 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

    Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.

    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 escalation arrangements for outstanding x-ray requests

    Wider context from the report

    “2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x-ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place. This is something that can be missed in a busy department. ”

    Source location

    Michael Nestor WYSOCKYJY · 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

    Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.

    Verbatim wording from the response

    “Response: The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, this should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted).”

    Source location

    Response from NHS Queen Elizabeth Hospital Kings's Lynn
    Page 2 · response
    Published 24 May 2022

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Mrs Elizabeth Glen Self · 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 Elizabeth Glen Self was admitted to hospital following a heart attack and later suffered a serious fall after becoming entangled in a line attached to her left leg. Injuries were not immediately recognised, and there were delays of more than thirteen hours in dealing with requested x-rays and a CT scan. The concerns included inadequate training in making x-ray requests, a possible breakdown in communications, and systems that allowed imaging requests to remain unresolved for hours.

    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 necessary training for senior staff making x-ray requests

    Wider context from the report

    “a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications. c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution. ”

    Source location

    Mrs Elizabeth Glen Self · 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 systems to ensure timely resolution of x-ray and CT requests

    Wider context from the report

    “a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications. c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution. ”

    Source location

    Mrs Elizabeth Glen Self · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Central Hampshire

    AI-generated summary

    Joan Elizabeth Betteridge · 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

    Joan Elizabeth Betteridge, aged 88, died during surgery for a displaced fractured neck of femur after a series of falls and delays in identifying the fracture. She developed bradycardia shortly after bone cement was inserted and was pronounced dead despite resuscitation attempts; the post-mortem identified bone cement implantation syndrome, with ischaemic heart disease as a contributory condition. The concerns included delays in requesting and progressing repeat X-rays and a radiology review system that did not identify the fracture promptly.

    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 timely making and progression of X-ray requests

    Wider context from the report

    “I heard evidence that ████████ intended to request a repeat X-ray on 1 June but nothing happened until the physiotherapist queried this with a different GP in the same surgery. This raises concerns either that the request was not made or if it was made then it was not progressed in a timely fashion. A further request was made on 7 June and took place on 9 June, two days later. ”

    Source location

    Joan Elizabeth Betteridge · 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 the procedure for requesting X-rays and discuss it with surgery doctors and staff.

    Verbatim wording from the response

    “████████ has undertaken a review of the procedure for requesting an X-ray and has discussed this with the doctors and staff at the surgery. Printed X-ray forms could cause a possible delay if they were to be collected from the surgery or have the potential to be mislaid if left at the patient’s home or residential faculty. Now that we have recently been given access to electronic X-ray forms it has been decided that doctors are to send X-ray forms electronically to the hospital rather than printing the forms. We have reminded all doctors that instructions to residential care staff and nurses should continue to be recorded clearly in the patient’s notes, as well as communicated explicitly, in order to avoid confusion regarding the management plan at a later stage.”

    Source location

    2018-0026-Response-by-St-Francis-Surgery
    Page 1 · response
    Published 20 March 2018

    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

    Send X-ray forms electronically to the hospital instead of printing them.

    Verbatim wording from the response

    “████████ has undertaken a review of the procedure for requesting an X-ray and has discussed this with the doctors and staff at the surgery. Printed X-ray forms could cause a possible delay if they were to be collected from the surgery or have the potential to be mislaid if left at the patient’s home or residential faculty. Now that we have recently been given access to electronic X-ray forms it has been decided that doctors are to send X-ray forms electronically to the hospital rather than printing the forms. We have reminded all doctors that instructions to residential care staff and nurses should continue to be recorded clearly in the patient’s notes, as well as communicated explicitly, in order to avoid confusion regarding the management plan at a later stage.”

    Source location

    2018-0026-Response-by-St-Francis-Surgery
    Page 1 · response
    Published 20 March 2018

    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 the default ICE request location on the affected emergency-department computer to the emergency department.

    Verbatim wording from the response

    “The default location on that computer has since been changed to the emergency department. I am pleased to confirm that the other computers in the emergency department that are used for accessing ICE were already set to the correct default location.”

    Source location

    2018-0026-Response-by-Hampshire-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    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

    Educate emergency-department clinicians on correctly recording X-ray request locations in ICE.

    Verbatim wording from the response

    “████████ Clinical Lead for Emergency Medicine, has also confirmed that the clinicians working in the emergency department have been educated on the importance of correctly recording the location of the requests, since this directly affects the timeframes for radiological review and reporting of images.”

    Source location

    2018-0026-Response-by-Hampshire-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    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

    Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements

    Wider context from the report

    “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI. The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed. ”

    Source location

    Harry Pryal · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. Central and South East Kent

    AI-generated summary

    Herbert Chandler · 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

    Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

    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 request a chest X-ray before aspiration

    Wider context from the report

    “A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”

    Source location

    Herbert Chandler · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026