Recurring concern

Failure to provide sufficient clinical information for diagnostic imaging interpretation

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First reported 20 Jun 2014•Latest report 26 Aug 2025

Definition

What this concern includes

Includes failures in the dedicated diagnostic-imaging information process where requests or interpretation referrals omit, inadequately describe or inconsistently communicate the indication, relevant clinical history, symptoms or changes in symptoms needed for safe image interpretation.

Not included

Excludes failures of image acquisition, scan availability, modality selection or reporting timeliness when the clinical-information provision itself is not deficient.
Excludes failures to interpret or act on imaging findings after sufficient clinical information has been provided.
Excludes generic clinical documentation, communication or referral deficiencies that are not specifically tied to information supplied for diagnostic imaging interpretation.
Excludes information deficiencies concerning non-imaging investigations or treatment decisions.

Reports: 4
Individual concerns: 5
Date range: 2014–2025
Stated actions: 10

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.

General Medical Council1

North Cumbria Integrated Care NHS Foundation Trust1

Royal College of Emergency Medicine1

South Tyneside and Sunderland NHS Foundation Trust1

The Society and College of Radiographers1

West Suffolk Hospital1

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.

26 Aug2025
Sunderland
Concerns raised1
1. Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation
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 4
1. Action
  Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated in progress
2. Action
  Develop a work instruction specifying the required clinical information for radiology examinations to proceed.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated planned
3. Action
  Issue Trust-wide communication updating current staff about the required clinical information for radiology requests.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated planned
1. Action
  Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated planned
AI-generated summary

Anne Lorraine Dyson · 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

Anne Lorraine Dyson died at St Benedict's hospice on 24 February 2025 after metastatic lung cancer was diagnosed in November 2024, following investigation for lung disease since September 2021. An incorrect interpretation of a CT scan in March 2024 significantly delayed diagnosis, by which time the cancer had progressed to a terminal stage. Concerns included inconsistent and limited clinical information provided to radiologists, potentially leading to restricted scan interpretation and delayed diagnosis and treatment.

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 provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation
Wider context from the report
“The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies greatly in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed. ”
Source location
Anne Lorraine Dyson · 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
Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.

Verbatim wording from the response
“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025
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
Develop a work instruction specifying the required clinical information for radiology examinations to proceed.

Verbatim wording from the response
“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025
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
Issue Trust-wide communication updating current staff about the required clinical information for radiology requests.

Verbatim wording from the response
“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025
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
Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.

Verbatim wording from the response
“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025
Open published response
25 Sep2023
Newcastle and North Tyneside
Concerns raised2
1. Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
2. Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information
This report raised 3 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 5
1. Action
  Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated completed
2. Action
  Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated completed
3. Action
  Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
1. Action
  Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
2. Action
  Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated completed
Respondent positions 3
1. Position
  Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.
  Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to act
1. Position
  Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.
  Stated by North Cumbria Integrated Care NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.
  Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concern
AI-generated summary

Brian David MORETON · 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

Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

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
Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
Wider context from the report
“- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”
Source location
Brian David MORETON · 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 telephone referrals and imaging summaries to provide accurate, consistent clinical information
Wider context from the report
“- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”
Source location
Brian David MORETON · 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
Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.

Verbatim wording from the response
“In August 2022, the Trust ratified a protocol, which sets out a clear referral flow chart for the authorisation of CT imaging for adults. If a CT scan is indicated, the patient must be reviewed or discussed with a senior decision maker within the referring team, and the referrer must make a written referral on ICE (as is the process for all imaging), with reference to who the senior decision maker is within the referral. If the request falls within the Rapid Radiology Request Pathway (“RRRP”) criteria below, this can be discussed with a CT Radiographer without the requirement to discuss this with a Radiologist or the referrer:”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023
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
Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.

Verbatim wording from the response
“The Trust however recognises that there may be occasions where referrers and the Radiology Department need to discuss a referral. As aforementioned, such discussions were not documented or recorded at the time of Mr Moreton’s admission. The Radiology Department utilises RIS (radiology information system) which has the ability to document any relevant information, and each Radiologist has access to the system. Following Mr Moreton’s death, Radiology staff have been reminded of situations where it might be appropriate to record information on RIS, particularly discussions during the justification process, which could be reviewed by the Reporting Radiologist, if the imaging was justified by another Radiologist.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
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
Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

Verbatim wording from the response
“Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within various policies and SOPs, it would appear that this system has lost momentum within the Trust. SBAR is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to achieve this. Clinicians will be expected to utilise SBAR in any escalation of a clinical problem that requires attention, or to facilitate efficient handover, both internally and externally.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023
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
Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.

Verbatim wording from the response
“The Trust recognises that if most requests for imaging are managed via written referral on ICE, there is a need to ensure that such referrals are robust. A robust referral should contain high-quality clinical information, which enables the Radiology Department to determine the most appropriate investigation or procedure to be selected, that takes into account patient safety, radiation exposure, and diagnostic value. It also provides a reason for the investigation through a clear diagnostic question that the referrer wants answering, to assist the Radiologist in the interpretation of results, minimising perceptual and interpretational diagnostic errors, and the subsequent completion of a pertinent and concise report.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023
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 ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.

Verbatim wording from the response
“The purpose of diagnostic imaging is to assist in the process of identifying or determining the etiology of a disease or condition, alongside the evaluation of a patient’s history, physical examination, and review of laboratory data. Reaching a diagnosis provides a trajectory of treatment and an understanding of a patient’s prognosis, and in some cases, may be useful for preventative treatments. However, in order to justify diagnostic imaging (to provide assurance that the benefits outweigh the risks) it is necessary to provide a differential diagnosis, which the imaging seeks to evidence or rule out. A differential diagnosis of query obstruction was included within Mr Moreton’s ICE referral, but toxic megacolon was not considered as an explanation for his presentation during his admission.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 5 October 2023
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
Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.

Verbatim wording from the response
“Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
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
Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.

Verbatim wording from the response
“Furthermore, there is no longer the expectation or requirement for referrers to discuss referrals for any imaging with a Radiologist. Whilst the duty line is still operational for referrers, Radiographers and Radiologists to discuss any requests being made, it is process for a robust ICE written referral to be made, and it is on that basis that the majority of imaging requests are justified or rejected, either by a Radiographer or Radiologist (depending on the above criteria), without the need for further discussion.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023
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
Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.

Verbatim wording from the response
“Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
Open published response
3 Apr2020
Surrey
Concerns raised1
1. Insufficiently detailed clinical information for radiographer X-ray reviews
This report raised 2 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 1
1. Action
  Ensure Society of Radiographers members are informed of the approved Clinical Imaging Board guidance on employer and referrer responsibilities under IR(ME)R 17.
  Stated by The Society and College of RadiographersStated planned
Respondent positions 1
1. Position
  Employers, rather than the Society, have overarching responsibility for ensuring referrers are trained in IR(ME)R 17 requirements.
  Stated by The Society and College of RadiographersRedirects responsibility
AI-generated summary

Andrew Spencer Wing · 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

Andrew Spencer Wing had a history of untreated hypertension and was discharged from hospital after investigations for acute left-sided pain, without a CT aorta being undertaken. He subsequently died from the effects of an aortic dissection. The principal concerns were that the chest X-ray and recognised possibility of aortic dissection should have led to a CT aorta, and that radiographers reviewing X-rays were given sparse clinical information.

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
Insufficiently detailed clinical information for radiographer X-ray reviews
Wider context from the report
“2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews. ”
Source location
Andrew Spencer Wing · Prevention of Future Deaths report
Page 3 · 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
Ensure Society of Radiographers members are informed of the approved Clinical Imaging Board guidance on employer and referrer responsibilities under IR(ME)R 17.

Verbatim wording from the response
“The SoR works in partnership with the Royal College of Radiologists and the Institute of Physics and Engineering in Medicine to promote understanding of IR(ME)R 17. We do this through a collaborative body, the Clinical Imaging Board. New guidance is currently in preparation and is expected to be approved in the near future. This will include the responsibilities of employers and referrers under the legislation. The following extract is from an advanced draft:”

Source location
2020-0089-Response-from-the-Society-of-Radiographers_Redacted
Page 1 · response
Published 20 April 2020
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
Employers, rather than the Society, have overarching responsibility for ensuring referrers are trained in IR(ME)R 17 requirements.

Verbatim wording from the response
“In the case of Mr Wing, the clinician that referred him for the chest x-ray should have been aware of the requirements to provide sufficient clinical information to justify the procedure and to enable a diagnostic report to be subsequently made. The employer has an over-arching responsibility to ensure all referrers within their authority are trained in the requirements of IR(ME)R 17.”

Source location
2020-0089-Response-from-the-Society-of-Radiographers_Redacted
Page 1 · response
Published 20 April 2020
Open published response
20 Jun2014
Suffolk
Concerns raised1
1. Failure to include sufficient clinical information in radiograph and other imaging requests
This report raised 3 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

Else Merete-Harvey Samuel · 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

Else Merete-Harvey Samuel was admitted to hospital after a fall, with continuing groin pain and a possible hip or pelvic fracture. Although initial radiographs did not show a fracture, some repeat views, including the pelvis, were not taken; a pelvic fracture was found at post mortem, alongside significant natural disease. The principal concerns were incomplete clinical information on imaging requests, insufficient senior discussion when investigations were challenged, and weaknesses in the subsequent 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 to include sufficient clinical information in radiograph and other imaging requests
Wider context from the report
“(1) Doctors requesting radiographs or other imaging investigations (whether out of hours or not) must include sufficient clinical information to explain why the investigation is indicated to avoid the request being rejected, and also to inform the radiologist who reports on the subsequent images what the relevant clinical history was. ”
Source location
Else Merete-Harvey Samuel · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation

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

Concerns raised2

Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians

Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Insufficiently detailed clinical information for radiographer X-ray reviews

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to include sufficient clinical information in radiograph and other imaging requests

Actions described in response 4

Actions described in response 5

Respondent positions 3

Actions described in response 1

Respondent positions 1