Recurring concern

Unreliable timeliness of radiology imaging and reporting

First to latest report 15 Oct 2013 — 4 Mar 2026

Reports that mention this concern
29
Times this concern has been raised
31
Stated actions linked to this concern
44

What this concern includes

Includes failures in radiology processes that delay or prevent clinically required imaging, reporting or access to radiology services, including unrealistic or unmet reporting-time expectations, delayed scan performance or reporting, burdensome request routes and inadequate out-of-hours arrangements.

What is not included
  • Excludes failures limited to interpretation of images where imaging and reporting were timely and available.
  • Excludes non-radiology investigations and generic diagnostic delays without a specific radiology connection.
  • Excludes condition-specific imaging pathways where a more specific named concern provides the supported boundary.
  • Excludes generic staffing, communication or IT deficiencies unless they directly impair timely radiology imaging, reporting or access.

Reports and published responses 29 reports

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

  1. North West Kent

    AI-generated summary

    Sandra Rhoda Marion Wood · 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

    Sandra Rhoda Marion Wood was sent to Tunbridge Wells Hospital on 17 April 2015 with a suspected bowel obstruction and was discharged with a diagnosis of UTI and constipation. She was found collapsed at home the following day, taken to Maidstone General Hospital, and died later that day; the post-mortem recorded bowel obstruction due to adhesions. The concerns included the lack of routine weekend CT scanning facilities, the procedure required for urgent scans, and the delay to scanning until after the weekend.

    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 weekend facilities for routine CT scans

    Wider context from the report

    “(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”

    Source location

    Sandra Rhoda Marion Wood · Prevention of Future Deaths report
    Page 1 · 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

    The Trust disputes that weekend CT facilities are unavailable, stating emergency scans are provided without numerical restriction based on clinical need.

    Verbatim wording from the response

    “1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends.”

    Source location

    sandra-wood-Response
    Page 1 · response
    Published 12 February 2016

    Open published response

  2. Inner North London

    AI-generated summary

    Shalini GANESH-RAM · 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

    Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

    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

    Delays in performing and reporting planned CT scans

    Wider context from the report

    “2. When a plan was made at 1.30pm on Sunday the 9ᵗʰ for a CT scan, this was not performed and reported on until approximately 7.30pm that evening. ”

    Source location

    Shalini GANESH-RAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. 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

    Lack of triage procedures for urgent or unexpected significant x-ray findings

    Wider context from the report

    “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines, although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay. WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination. An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay. ”

    Source location

    Harry Pryal · 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 and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.

    Verbatim wording from the response

    “A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway. This includes, and has started with the service level agreement for the provision of radiology services. The review process will incorporate the following steps:”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 2 · response
    Published 28 September 2015

    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 staff that Lakeside Unit patients must be treated as inpatients and update CRIS to reflect that status.

    Verbatim wording from the response

    “In the case of Mr Pryal, the x-rays undertaken by 5BP at Leigh Infirmary were treated the same as if he were based at an out-patient facility. It is acknowledged that there was a lack of understanding by health professionals at the Trust that Lakeside Unit is an inpatient facility. Mr Pryal’s x-rays should have been reviewed as if he was an inpatient, and then they would have been reported sooner.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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 weekday hot reporting of x-rays as soon as possible after examination.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Train reporting radiographers to interpret chest x-rays and expand specialist radiographer reporting capacity.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Hot reporting is not available at weekends because of resource constraints.

    Verbatim wording from the response

    ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 5 · response
    Published 28 September 2015

    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

    Local providers are responsible for reviewing local systems concerning X-ray reporting, electronic viewing and patient-note recording.

    Verbatim wording from the response

    “You outline the circumstances which led to this situation and direct several concerns to the 5 Boroughs Partnership NHS Foundation Trust (5BP) and Wrightington Wigan and Leigh NHS Foundation Trust (WWL) which relate to their joint Service Agreement, the reporting times for X-rays, the electronic systems available to support web viewing of X-rays and the recording of appropriate patient notes. These concerns are about the local systems that are in place and rightly addressed to the local providers, who I am confident will consider and review.”

    Source location

    2015-0391-Response-by-Department-of-Health
    Page 1 · response
    Published 28 September 2015

    Open published response

  4. Blackpool and the Fylde

    AI-generated summary

    Olive Darbyshire · 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

    Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.

    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 complete urgent CTPA requests promptly

    Wider context from the report

    “1. Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, I am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place and that this had not happened some three days after the request was made. ”

    Source location

    Olive Darbyshire · 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

    Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.

    Verbatim wording from the response

    “There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weaknesses regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.”

    Source location

    Olive-Darbyshire-Response
    Page 2 · response
    Published 22 May 2015

    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

    Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.

    Verbatim wording from the response

    “This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.”

    Source location

    Olive-Darbyshire-Response
    Page 2 · response
    Published 22 May 2015

    Open published response

  5. Manchester South

    AI-generated summary

    John Michael Matthews · 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

    John Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

    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

    Delays in sending patients for a head CT scan

    Wider context from the report

    “4. There was an unnecessary and to some extent unexplained delay in sending him for a CT scan of his head. ”

    Source location

    John Michael Matthews · 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

    Institute ED checklists preventing patients from leaving before requested investigations and treatments are completed.

    Verbatim wording from the response

    “For the future, to avoid a reoccurrence of this incident, we have instituted a system of checklists whereby a patient cannot leave the ED without all the investigations and treatments being completed. The investigations requested are clearly shown on Advantis ED therefore the nurse caring for the patient and the shift co-ordinator will be aware of investigations requested.”

    Source location

    2015-0034-Response-by-Stockport-NHS-Trust
    Page 3 · response
    Published 29 January 2015

    Open published response

  6. Inner North London

    AI-generated summary

    Stephen Atherton · 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

    Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

    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

    Delays in radiologist-recommended additional investigations when GPs cannot request them

    Wider context from the report

    “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays. This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations. This is particularly the case where the suggested investigations cannot actually be requested by GPs. The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case. ”

    Source location

    Stephen Atherton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Joyce Nelson · 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

    Joyce Nelson fell at home on 7 March 2014 and fractured her pelvis in several places. The report raises concerns about delays in medical assessment, documentation and imaging results at the Emergency Department, and that she was to be discharged despite having a multi-fractured pelvis; it states that the delays were linked to reported shortages of emergency medicine doctors and radiologists.

    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

    Delays in reporting imaging results

    Wider context from the report

    “4. There were very considerable delays in reporting the imaging results, and I was told that this is due to a national shortage of Radiologists. ”

    Source location

    Joyce Nelson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Robert Erryl Jones · 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

    Robert Erryl Jones was admitted for bowel surgery and remained in hospital as his health declined. Delays in reporting and acting on the results of an emergency CT scan led to a significant delay in further surgery. The principal concern was that CT scan results should be made available promptly to the relevant departments and acted upon without delay where appropriate.

    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 make CT scan results promptly available to departments involved in patient care

    Wider context from the report

    “That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale. ”

    Source location

    Robert Erryl Jones · 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

    Monitor emergency CT scan reporting times through routine sampling.

    Verbatim wording from the response

    “The Health Board fully recognises the need to ensure CT scan results should be made available promptly and will ensure that this is routinely monitored. The Radiology department will be undertaking sampling of the scan to report time for emergency CT scans.”

    Source location

    2014-0190-Response
    Page 1 · response
    Published 20 March 2014

    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

    Ensure test results are available to all relevant clinical teams when patients are under the care of multiple teams.

    Verbatim wording from the response

    “Any test results which are given verbally, as maybe the case in an emergency situation, must also be appropriately documented in the patient record. We will also ensure that where patients may be under the care of several different clinical teams that test results are made available to any members of those teams.”

    Source location

    2014-0190-Response
    Page 1 · response
    Published 20 March 2014

    Open published response

  9. Black Country

    AI-generated summary

    Lucy KILVERT · 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

    Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.

    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

    Delays in performing a CT scan of the head after hospital presentation

    Wider context from the report

    “namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”

    Source location

    Lucy KILVERT · 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.

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Data last updated 7 September 2026