Recurring concern

Unreliable chest X-ray imaging and interpretation

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First reported 1 Aug 2014•Latest report 4 Mar 2026

Definition

What this concern includes

Includes failures in the dedicated chest X-ray process from acquisition and anatomical marking through labelling, image access, viewing, interpretation, documentation and consideration of the images when these deficiencies can compromise diagnosis or treatment.

Not included

  • Excludes CT, MRI, ultrasound and other imaging modalities unless the assertion explicitly concerns the same chest X-ray process.
  • Excludes failures occurring after a chest X-ray has been reliably interpreted, such as downstream referral or treatment failures.
  • Excludes generic radiology staffing, IT, communication or documentation deficiencies unless they directly impair chest X-ray acquisition, access, interpretation or clinical use.
  • Excludes chest-drain insertion or other procedures unless the asserted deficiency is specifically the associated chest X-ray process.
Reports
5

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1
Department of Health and Social Care1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Mid and South Essex NHS Foundation Trust1
Royal College of Anaesthetists1
Royal College of Emergency Medicine1
Royal College of Paediatrics and Child Health1
Royal United Hospital1
Stepping Hill Hospital1
The British Thoracic Society1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Viviana-Ray Winnie Elsie Wendy Butnaru · 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

    Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.

    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 official radiologist reporting of chest X-rays showing cardiomegaly

    Wider context from the report

    “(3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later. ”

    Source location

    Viviana-Ray Winnie Elsie Wendy Butnaru · 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

    Complete and formalise the radiology policy review to document how clinical teams can expedite imaging reports for clinical concerns.

    Verbatim wording from the response

    “The Radiology Department identified that guidance for clinical teams on how to expedite an imaging report due to clinical concern was not documented in Trust radiology policies and procedures. As such, the Director of Nursing has confirmed that a review of the Trust’s policy, Guide for making the best use of a Radiology Department (MSEGL23134) will be completed by 1 June 2026 to ensure an updated version is formalised to include this guidance going forward. The Trust will be able to share a copy of this updated policy with you in due course if it is of assistance.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 9 March 2026

    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

    Share the updated radiology escalation guidance with paediatric teams and publish it on the Trust intranet.

    Verbatim wording from the response

    “As a result of these guideline changes, targeted sharing of the changes will be undertaken with the Paediatric teams across our sites within MSEFT, alongside the updated guideline being available on the Trust's intranet page, which is accessible for all staff.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 9 March 2026

    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

    Formal chest X-ray reporting delays lie outside the respondent’s control.

    Verbatim wording from the response

    “• Chest X ray reporting. This lies outside of our control but we recognise that there is often some delay between images being taken in the context of an emergency and a formal report being issued. All clinicians have some training in interpreting chest X rays.”

    Source location

    Response from The Royal College of Paediatrics and Child Health
    Page 2 · response
    Published 9 March 2026

    Open published response

  2. Surrey

    AI-generated summary

    ARTHUR FREDERICK HALL · 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

    Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of 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

    Failure to account for the limited sensitivity of upright chest X-rays when excluding perforation

    Wider context from the report

    “2. The recognised first line of enquiry was an upright chest X-ray. What is known about upright chest Xray’s is that they are known to miss a number of perforations. This was used to exclude the possibility of perforation when it is a known limited diagnostic tool that can miss from 20% of perforations to 50% of perforations (see literature). ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. West London

    AI-generated summary

    Dennis Peter Alfred Warner · 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

    Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.

    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

    Use of suboptimal chest X-ray imaging after chest injury

    Wider context from the report

    “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate. ”

    Source location

    Dennis Peter Alfred Warner · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Glenys Pollitt · 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

    Glenys Pollitt was admitted to Stepping Hill Hospital with community acquired pneumonia, but surgical emphysema and an oesophageal rupture were not identified on an initial x-ray and subsequent reviews. She underwent emergency surgery after the rupture was identified, deteriorated, and died from multi-organ failure on 16 February 2017. Concerns included inconsistent use of high-resolution x-ray screens, unclear reinforcement of clinical learning, and unclear escalation processes to consultant and critical care levels.

    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

    Inconsistent use of high-resolution screens for viewing x-rays

    Wider context from the report

    “1. It was accepted during the evidence that the x ray should ideally be viewed on a high-resolution screen rather than an standard screen. This increased the likelihood of significant abnormalities being detected. There are a number of such high-resolution screens for viewing of x rays. The evidence indicated that there was differing practice across the hospital as to when such screens were used and by whom. ”

    Source location

    Glenys Pollitt · 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 to assess the whole x-ray image rather than only expected findings

    Wider context from the report

    “2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians; ”

    Source location

    Glenys Pollitt · 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

    Draft guidance identifying high-resolution screens, access arrangements and support across the Trust.

    Verbatim wording from the response

    “The Trust’s Radiology Systems Manager has confirmed that the standard screens available in ED are of a high enough resolution to view chest x ray images. The Radiology Systems Manager has drafted a document, which is awaiting their Business Group Quality Governance Board sign off, to list where all high resolution screens are within the Trust, how to access them and how to gain support to view images on them, should it be required.”

    Source location

    2017-0228-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 6 October 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Standard Emergency Department screens are sufficiently high resolution, and screen resolution was not identified as affecting diagnosis.

    Verbatim wording from the response

    “The Trust’s Radiology Systems Manager has confirmed that the standard screens available in ED are of a high enough resolution to view chest x ray images. The Radiology Systems Manager has drafted a document, which is awaiting their Business Group Quality Governance Board sign off, to list where all high resolution screens are within the Trust, how to access them and how to gain support to view images on them, should it be required.”

    Source location

    2017-0228-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 6 October 2017

    Open published response

  5. Avon

    AI-generated summary

    Gerald Trevor WERRETT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incorrect interpretation of the cardiac silhouette

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Misinterpretation of chest x-rays

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use a lead anatomical marker when taking chest x-rays

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure by clinicians to identify incorrectly labelled chest x-rays

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider both chest x-rays

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incorrect labelling of chest x-rays

    Wider context from the report

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

    Source location

    Gerald Trevor WERRETT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response
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Data last updated 7 September 2026