26 Aug 2025 Anne Lorraine Dyson · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
South Tyneside and Sunderland NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
South Tyneside and Sunderland NHS Foundation Trust
Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.
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South Tyneside and Sunderland NHS Foundation Trust
Develop a work instruction specifying the required clinical information for radiology examinations to proceed.
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South Tyneside and Sunderland NHS Foundation Trust
Issue Trust-wide communication updating current staff about the required clinical information for radiology requests.
View source
South Tyneside and Sunderland NHS Foundation Trust
Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.
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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.
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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
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
Concerns raised 2
Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians View source Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North Cumbria Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
North Cumbria Integrated Care NHS Foundation Trust
Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.
View source
North Cumbria Integrated Care NHS Foundation Trust
Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.
View source
North Cumbria Integrated Care NHS Foundation Trust
Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.
View source
North Cumbria Integrated Care NHS Foundation Trust
Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.
View source
North Cumbria Integrated Care NHS Foundation Trust
Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.
View source See 2 more actions
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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.
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× 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
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
Open source report
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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
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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
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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
Open published response
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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
Open published response
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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
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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
Open published response
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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
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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
Open published response
3 Apr 2020 Andrew Spencer Wing · Prevention of Future Deaths report Surrey
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Concerns raised 1
Insufficiently detailed clinical information for radiographer X-ray reviews View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
Open source report
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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
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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
Open published response
20 Jun 2014 Else Merete-Harvey Samuel · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to include sufficient clinical information in radiograph and other imaging requests View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.