Recurring concern

Failure to provide timely urgent diagnostic investigations

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First reported 29 Sep 2013•Latest report 18 Dec 2025

Definition

What this concern includes

Includes failures in the process for providing clinically urgent diagnostic investigations, including ordering or initiation, scheduling, performance, reporting and timely availability for clinical review, across diagnostic modalities and clinical settings.

Not included

Excludes routine or non-urgent diagnostic waiting times where urgency is not identified.
Excludes failures limited to interpretation or clinical action after a result was timely available, unless the investigation's reporting or availability was also deficient.
Excludes generic staffing, communication, capacity or documentation deficiencies unless they directly cause delay or unreliability in providing an urgent diagnostic investigation.
Excludes a separately named diagnostic pathway or modality concern where that named system supplies the more specific supported parent boundary.
Excludes delays in treatment, referral or specialist review where no urgent diagnostic-investigation failure is identified.

Reports: 24
Individual concerns: 27
Date range: 2013–2025
Stated actions: 66

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.

Department of Health and Social Care4

NHS England2

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Barts Health NHS Trust1

Bedfordshire Hospitals NHS Foundation Trust1

Betsi Cadwaladr University LHB1

Care Quality Commission1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Doncaster Royal Infirmary1

East Lancashire Hospitals NHS Trust1

Glan Clwyd Hospital1

Glangwili General Hospital1

Husband of the deceased1

King's College Hospital1

Maidstone and Tunbridge Wells NHS Trust1

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.

4 Apr2019
West Yorkshire Eastern
Concerns raised1
1. Delays in reporting CT scans within the Trust’s five-day timescale
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Apply internal radiology reporting turnaround guidance that prioritizes examinations by modality, urgency and referral pathway.
  Stated by Mid Yorkshire Teaching NHS TrustStated completed
2. Action
  Monitor radiology reporting turnaround times as a key performance indicator and report performance to divisional management and the Trust Board.
  Stated by Mid Yorkshire Teaching NHS TrustStated completed
3. Action
  Manage outstanding radiology reporting through a clinically prioritized queue, allocating resources to acute, urgent and cancer pathways to mitigate backlog risks.
  Stated by Mid Yorkshire Teaching NHS TrustStated completed
Respondent positions 3
1. Position
  The five-day reporting timeframe was incorrect for the routine outpatient CT examinations, and reporting delays did not contribute to the death.
  Stated by Mid Yorkshire Teaching NHS TrustDisputes the concern
1. Position
  Current prioritisation, monitoring, internal turnaround guidance and risk-management arrangements are considered sufficient while reporting backlogs are managed.
  Stated by Mid Yorkshire Teaching NHS TrustExisting arrangements considered sufficient
2. Position
  National standards and clear safety frameworks for radiology reporting turnaround times are assigned to national imaging, radiology and radiographer bodies.
  Stated by Mid Yorkshire Teaching NHS TrustRedirects responsibility
AI-generated summary

Mr Alfred Howell · 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

Mr Alfred Howell was admitted to hospital after respiratory deterioration, including bilateral pleural effusions and partial lung collapse. His condition deteriorated, and he suffered a cardiac arrest and died on 5 June 2018. The principal concern was that CT scans took 14 and 12 days to be reported, exceeding the Trust’s five-day target, although the inquest evidence did not indicate that the delays contributed to his death.

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 CT scans within the Trust’s five-day timescale
Wider context from the report
“During investigations into Mr Howell’s medical condition, CT scans were taken on a number of occasions. Specifically, he underwent a CT scan on 24th March 2018 which was reported on by the radiology department on 7th April 2018. Upon review at an MDT on 17th April 2018, a deterioration of the changes previously seen in both lungs was noted. An MDT plan was then to perform an early follow up CT to assess whether the changes might prove given that he had further antibiotic treatment for infection. The repeat scan took place on 17th May 2018 and was reported by the outsource company TMC on 29th May 2018. At that stage the scan was abnormal and significantly deteriorated and was brought to the attention of the Consultant in Respiratory and General Medicine. There had been an increase in the areas of consolidation, an increase in the size of now bilateral pleural effusions and both lungs had collapsed slightly. The Consultant took immediate steps to facilitate Mr Howell’s admission to hospital. The Consultant who provided evidence at the Inquest commented that a period of 5 days from CT scan to reporting by radiology is the timescale target within the Trust. The aforesaid scans took 14 days and 12 days to be reported on respectively. The latter scan was brought to the Consultant’s attention immediately. Mr Howell continued under investigation for a diagnosis and was treated appropriately. Whilst the evidence at the Inquest did not indicate any contribution by delays in the scans to his death, I am concerned that upon the evidence given that the reporting of scans fell outwith an aimed for timescale of 5 days and that this could impact the treatment of others patients in the future. I am under a duty to report this matter upon consideration of the evidence. ”
Source location
Mr Alfred Howell · 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
Apply internal radiology reporting turnaround guidance that prioritizes examinations by modality, urgency and referral pathway.

Verbatim wording from the response
“The prioritisation of image acquisition and reporting has to be tailored for different pathways, for example whilst it may be acceptable that outpatient reports are not provided on the day of acquisition, this is clearly not acceptable for emergency department patients. As there is no nationally mandated standard for the reporting turnaround of examinations at Mid Yorkshire NHS Hospitals, we apply our own guidance on the expected reporting turnaround times of radiology examinations. Different priority is given to different examinations depending on the modality (Xray, CT, MRI, Ultrasound), urgency of the request (as indicated by the referrer) and the referral source e.g. Emergency Department, Inpatient vs outpatient & GP referral. We are also asked to prioritise patients on fast track cancer pathways meaning”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 1 · response
Published 9 June 2019
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
Monitor radiology reporting turnaround times as a key performance indicator and report performance to divisional management and the Trust Board.

Verbatim wording from the response
“Reporting turnaround times are a key performance indicator for the radiology department. As such they are monitored internally by the radiology department, divisional management team and reported to the Trust Board. As an organisation we strive to deliver the highest quality healthcare so this focus helps us to reduce the numbers of patients who wait longer than the internal target for an examination report. Given the complexity of the workload and the challenges meeting the reporting turnaround we have a risk management approach to the outstanding reporting. Unreported examinations wait within a prioritised queue with resource prioritised to the strategic objectives of the organisation focussing on acute/clinically urgent and cancer pathways. The routine outpatient work load waits longer to be reported.”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 2 · response
Published 9 June 2019
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
Manage outstanding radiology reporting through a clinically prioritized queue, allocating resources to acute, urgent and cancer pathways to mitigate backlog risks.

Verbatim wording from the response
“Reporting turnaround times are a key performance indicator for the radiology department. As such they are monitored internally by the radiology department, divisional management team and reported to the Trust Board. As an organisation we strive to deliver the highest quality healthcare so this focus helps us to reduce the numbers of patients who wait longer than the internal target for an examination report. Given the complexity of the workload and the challenges meeting the reporting turnaround we have a risk management approach to the outstanding reporting. Unreported examinations wait within a prioritised queue with resource prioritised to the strategic objectives of the organisation focussing on acute/clinically urgent and cancer pathways. The routine outpatient work load waits longer to be reported.”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 2 · response
Published 9 June 2019
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
The five-day reporting timeframe was incorrect for the routine outpatient CT examinations, and reporting delays did not contribute to the death.

Verbatim wording from the response
“The matter of concern that you raise was “that upon the evidence given that the reporting of scans fell outwith an aim for timescale of 5 days and could impact the treatment of patients in the future”. Evidence at the inquest did not indicate that this had made any contribution to Mr Howell’s death.”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 1 · response
Published 9 June 2019
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
Current prioritisation, monitoring, internal turnaround guidance and risk-management arrangements are considered sufficient while reporting backlogs are managed.

Verbatim wording from the response
“The prioritisation of image acquisition and reporting has to be tailored for different pathways, for example whilst it may be acceptable that outpatient reports are not provided on the day of acquisition, this is clearly not acceptable for emergency department patients. As there is no nationally mandated standard for the reporting turnaround of examinations at Mid Yorkshire NHS Hospitals, we apply our own guidance on the expected reporting turnaround times of radiology examinations. Different priority is given to different examinations depending on the modality (Xray, CT, MRI, Ultrasound), urgency of the request (as indicated by the referrer) and the referral source e.g. Emergency Department, Inpatient vs outpatient & GP referral. We are also asked to prioritise patients on fast track cancer pathways meaning”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 1 · response
Published 9 June 2019
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
National standards and clear safety frameworks for radiology reporting turnaround times are assigned to national imaging, radiology and radiographer bodies.

Verbatim wording from the response
“2. The National Imaging Optimisation Delivery Board should advise on national standards for report turnaround times, so that trusts can monitor and benchmark their performance.”

Source location
2019-0116-Response-by-The-Mid-Yorkshire-Hospitals-NHS-Trust
Page 2 · response
Published 9 June 2019
Open published response
22 Jun2017
Inner South London
Concerns raised2
1. Failure to follow up ordered urgent investigations
2. Failure of referral systems to preserve urgent scan appointments when patients change from in-patient to out-patient status
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 4
1. Action
  Prepare a safety alert reminding members and fellows to ensure adequate follow-up arrangements for patients discharged from emergency departments.
  Stated by Royal College of Emergency MedicineStated in progress
2. Action
  Establish Consultant-led virtual reviews of patients self-discharged during the take period to confirm investigations and follow-up are arranged.
  Stated by King'S College Hospital NHS Foundation TrustStated in progress
3. Action
  Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
  Stated by King'S College Hospital NHS Foundation TrustStated planned
1. Action
  Appoint an administrator to coordinate communication and follow-up of abnormal radiology results for Emergency Department patients, including those discharged before reporting.
  Stated by King'S College Hospital NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
  Stated by King'S College Hospital NHS Foundation TrustDisputes the concern
1. Position
  Follow-up of proposed investigations is the responsibility of the team that ordered them, with the ordering team responsible for ensuring follow-up.
  Stated by King'S College Hospital NHS Foundation TrustRedirects responsibility
AI-generated summary

Constance Connolly · 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

Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from A&E.

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 follow up ordered urgent investigations
Wider context from the report
“There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
Source location
Constance Connolly · 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 referral systems to preserve urgent scan appointments when patients change from in-patient to out-patient status
Wider context from the report
“There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
Source location
Constance Connolly · 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
Prepare a safety alert reminding members and fellows to ensure adequate follow-up arrangements for patients discharged from emergency departments.

Verbatim wording from the response
“While these guidelines promote good governance about investigations that have already been performed, these do not address all of the issues identified in the report. In addition, we are preparing a safety alert for September 2017, reminding Members and Fellows to ensure follow up arrangements are adequate for patients discharged from the emergency department. We are considering, through our Quality in Emergency Care Committee whether there is a need for further guidance about on-going care for patients discharged from the emergency department.”

Source location
2017-0201-Response-by-The-Royal-College-of-Emergency-Medicine
Page 1 · response
Published 28 July 2017
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
Establish Consultant-led virtual reviews of patients self-discharged during the take period to confirm investigations and follow-up are arranged.

Verbatim wording from the response
“Finally, as mentioned above under Matter 1, the Trust is committed to ensuring the post-take Consultant undertakes a “virtual ward round” of any patient who has self-discharged during the take period, and reassures themselves they have received appropriate follow-up by way of signposting, appointments or otherwise.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 3 · response
Published 28 July 2017
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
Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.

Verbatim wording from the response
“• The ED tracking system (Symphony) is planned for an upgrade, which is due by October 2017. This will enable ED GP Discharge Notifications to highlight and distinguish which investigations have been done (ideally with a result if verified), which are booked and which are still pending.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 4 · response
Published 28 July 2017
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
Appoint an administrator to coordinate communication and follow-up of abnormal radiology results for Emergency Department patients, including those discharged before reporting.

Verbatim wording from the response
“The Hospital’s ED team are also due to appoint a new administrator to ensure communication and follow-up of abnormal radiology results for ED patients occurs appropriately and especially if reported as abnormal after they are discharged from ED.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 4 · response
Published 28 July 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
The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.

Verbatim wording from the response
“As a preliminary point, we note that none of the concerns raised in the Report caused or contributed to Mrs Connolly’s death in light of the Conclusion reached at the Inquest hearing on 24 May 2017, namely “Natural causes contributed to by unintended consequences of necessary medical treatment”. The Report in particular states that no failures of care contributed to Mrs Connolly’s death.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 1 · response
Published 28 July 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
Follow-up of proposed investigations is the responsibility of the team that ordered them, with the ordering team responsible for ensuring follow-up.

Verbatim wording from the response
“The Trust agrees follow-up of patients in terms of proposed investigations is the responsibility of the team who has ordered the investigation(s). An outpatient MRI scan appointment was made, but this should have been communicated more clearly to the GP. The “virtual review”, as described below under Matter 2, should facilitate clearer communication to health care colleagues, patients and families.”

Source location
2017-0201-Response-by-Kings-College-Hospital
Page 2 · response
Published 28 July 2017
Open published response
8 Mar2017
Manchester City
Concerns raised1
1. Delays in arranging urgent tests and treatment
This report raised 14 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

Mrs Kathleen Cooper · Prevention of Future Deaths report

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

Report summary

Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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 arranging urgent tests and treatment
Wider context from the report
“3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”
Source location
Mrs Kathleen Cooper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 May2016
Cumbria
Concerns raised1
1. Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans
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 6
1. Action
  Appoint three radiologists to increase reporting capacity.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completed
2. Action
  Continue recruitment, including international recruitment, to develop reporting capacity.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated in progress
3. Action
  Offer additional programmed activities and payment to consultants reporting work beyond contracted hours.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completed
1. Action
  Provide ad hoc reporting support through eight honorary contracts with external radiologists.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completed
2. Action
  Explore home reporting with the new PACS to improve recruitment and retention opportunities.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated planned
3. Action
  Roll out voice recognition technology across radiology staff to speed report turnaround.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completed
Respondent positions 5
1. Position
  Insufficient radiology reporting capacity prevents all imaging studies from being reported promptly, reflecting a wider national radiologist shortage.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustUnable to act
1. Position
  The existing scope of referrer evaluation and its standard operating procedure are considered reasonable and safe, so wider expansion is not preferred.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  A prioritisation flow diagram is not being constructed because clinical complexity across modalities does not permit reliable simplification.
  Stated by University Hospitals of Morecambe Bay NHS Foundation TrustUnable to act
3. Position
  Responsibility for staffing levels and skill mix rests with individual NHS Trust boards, considering local factors and safe-care requirements.
  Stated by Department of Health and Social CareRedirects responsibility
4. Position
  Urgent and emergency care networks are responsible for developing clinical pathways, designating services and monitoring performance and access.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Mrs Constance Pridmore · Prevention of Future Deaths report

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

Report summary

Mrs Constance Pridmore, who was living independently, fell accidentally on 3 May 2015 and was admitted to hospital with pneumonia. She died on 7 May 2015 from a haemothorax associated with fractured ribs, during insertion of a chest drain. The principal concern was that rib fractures and the associated haemothorax were not identified promptly because her admission chest X-ray was not reviewed by a radiologist until after her death, amid a shortage of 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 timely radiologist review and reporting of diagnostic X-rays and CT scans
Wider context from the report
“(1) It was confirmed in evidence by Consultant Radiologist ████████ that: a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist, but are assessed by the requesting physician. b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits. In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died. c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust. (2) It was confirmed in evidence by Consultant Physician ████████ that: a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently. b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome (3) It was confirmed in evidence by independent Consultant Radiologist, ████████ ████████ that: a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K. c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K. d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts. This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner. The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target. It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes, creates a foreseeable risk that further deaths may well arise as a consequence. Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary. ”
Source location
Mrs Constance Pridmore · 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
Appoint three radiologists to increase reporting capacity.

Verbatim wording from the response
“Clearly recruitment is central to developing further capacity and the Trust has made progress and appointed three radiologists in the past 12 months with ongoing recruitment efforts, including international recruitment.”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 3 · response
Published 12 May 2016
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
Continue recruitment, including international recruitment, to develop reporting capacity.

Verbatim wording from the response
“The Dalton Review reported that the UK has around 48 trained radiologists per million population. This figure has remained static for the last five years and represents half the total in other EU countries. The paper considers different ways of working in terms of outsourcing, skill mix and the use of technology to overcome the challenge and UHMB has already implemented some of these ideas. In the UK, no appointment was made to 41% of unfilled consultant posts advertised and the North West showed a higher vacancy rate than other regions. This reflects the experience in UHMB where there are currently 5 vacancies, based on workload calculations from 2011, since which time CT and MR have both doubled in volume and increased in complexity.”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 3 · response
Published 12 May 2016
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
Offer additional programmed activities and payment to consultants reporting work beyond contracted hours.

Verbatim wording from the response
“• Additional programmed activities and payment are on offer to substantive consultants to report additional work beyond their normal employed hours”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 3 · response
Published 12 May 2016
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 ad hoc reporting support through eight honorary contracts with external radiologists.

Verbatim wording from the response
“• 8 honorary contracts with external radiologists who provide ad hoc support”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 4 · response
Published 12 May 2016
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
Explore home reporting with the new PACS to improve recruitment and retention opportunities.

Verbatim wording from the response
“• Home reporting to be explored with the advent of new PACS from September 2016, which should improve recruitment and retention opportunities”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 4 · response
Published 12 May 2016
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
Roll out voice recognition technology across radiology staff to speed report turnaround.

Verbatim wording from the response
“• Voice recognition technology has been rolled out across all radiology staff, streamlining the process and speeding up report turnaround times”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 4 · response
Published 12 May 2016
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
Insufficient radiology reporting capacity prevents all imaging studies from being reported promptly, reflecting a wider national radiologist shortage.

Verbatim wording from the response
“The number and range of imaging investigations performed per day varies but the reporting workload is broadly predictable and University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) does not have sufficient reporting capacity to promptly report all the images that are acquired. As identified in your report, there is a shortage of radiologists and this is reflective of a national problem. The Royal College of Radiologists (RCR) has produced several snapshot surveys demonstrating the scale of the issue. The most recent RCR survey (February 2016) showed that in fact, UHMB was in the upper quartile with no studies >1 month.”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 1 · response
Published 12 May 2016
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
The existing scope of referrer evaluation and its standard operating procedure are considered reasonable and safe, so wider expansion is not preferred.

Verbatim wording from the response
“A small number of studies are considered suitable for 'referrer evaluation' and the opinion documented will be that of the referrer, with an option to ask for the film to be reviewed and reported by a radiologist. In these cases there would be no formal report issued by a radiologist. Examples of x-rays that are considered suitable for referrer evaluation at UHMB include x-rays of the teeth reviewed by a dentist and follow up x-rays of healing fractures in adults reviewed by an orthopaedic surgeon.”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 2 · response
Published 12 May 2016
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
A prioritisation flow diagram is not being constructed because clinical complexity across modalities does not permit reliable simplification.

Verbatim wording from the response
“The waiting images are actively managed by a radiographic manager who will also send work to outsourcing companies as required.”

Source location
2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Page 3 · response
Published 12 May 2016
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
Responsibility for staffing levels and skill mix rests with individual NHS Trust boards, considering local factors and safe-care requirements.

Verbatim wording from the response
“Responsibility for staffing rests, as it has always done, with Trust boards. Trusts should focus on the numbers and skill mix needed to deliver quality care, patient safety and efficiency, taking into account local factors such as acuity and case mix.”

Source location
2016-0491-Response-by-Department-of-Health
Page 2 · response
Published 12 May 2016
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
Urgent and emergency care networks are responsible for developing clinical pathways, designating services and monitoring performance and access.

Verbatim wording from the response
“NHS England reports that the Urgent and Emergency Care Review arising from Sir Bruce Keogh’s work is now in its implementation phase. Key to implementation is the development of urgent and emergency care (UEC) networks. In June 2015, NHS England published guidance for what were then emerging networks titled Role and Establishment of Urgent and Emergency Care Networks and in October a total of 23 UEC networks across the four regions of NHS England were confirmed.”

Source location
2016-0491-Response-by-Department-of-Health
Page 3 · response
Published 12 May 2016
Open published response
19 Apr2016
Birmingham and Solihull
Concerns raised1
1. Failure to reliably transmit CT scans between trusts for timely review
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 the Image Exchange Portal procedure to clarify transmission routes, contingencies and audit-trail documentation.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completed
2. Action
  Configure all SWBH CT scanners to send images to Birmingham Children’s Hospital.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
3. Action
  Secure approval and complete configuration for all SWBH CT scanners to send images to Heartlands Hospital.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated planned
1. Action
  Train all radiographers in the Image Exchange Portal and Image Link, with documented competency sign-off.
  Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progress
AI-generated summary

Leslie William Carswell · 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

Leslie William Carswell was admitted to hospital following a transcatheter aortic valve implantation, was assessed as being at high risk of falls, and suffered a serious brain bleed after falling while going to the toilet. The report raised concern that technical difficulties transmitting CT scans delayed review and treatment planning, with potential to delay lifesaving treatment for patients with urgent conditions.

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 reliably transmit CT scans between trusts for timely review
Wider context from the report
“(1) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth Hospital in Birmingham for review which is the protocol for these west midlands. This caused a delay in deciding a treatment plan. I heard evidence at the inquest that these concerns are ongoing and no resolution has been found. There is a concern that patients with urgent conditions could have lifesaving treatment delayed due to technical difficulties between the two trusts. ”
Source location
Leslie William Carswell · 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
Update the Image Exchange Portal procedure to clarify transmission routes, contingencies and audit-trail documentation.

Verbatim wording from the response
“1. Procedure – the Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and / or if there is a technical fault. The updated procedure includes changes to documentation requirements for audit trail purposes. This updated documentation procedure went live on 3 June 2016. System based audit trails are being looked into.”

Source location
2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Page 1 · response
Published 19 April 2016
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
Configure all SWBH CT scanners to send images to Birmingham Children’s Hospital.

Verbatim wording from the response
“2. System configuration – all three SWBH CT scanners can send images directly to UHB. One of the CT scanners at Sandwell Hospital can send to Birmingham Children’s Hospital. Work to ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham Children’s Hospital is in progress. Configuration to the Children’s Hospital is scheduled for completion by mid-June. A request for configuration work was submitted to IT colleagues at Heartlands in May 2016 and once approved it will take approximately two weeks to allow for firewall configuration and testing. These configurations will be a fixed point in our Managed Equipment Service specification.”

Source location
2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Page 1 · response
Published 19 April 2016
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
Secure approval and complete configuration for all SWBH CT scanners to send images to Heartlands Hospital.

Verbatim wording from the response
“2. System configuration – all three SWBH CT scanners can send images directly to UHB. One of the CT scanners at Sandwell Hospital can send to Birmingham Children’s Hospital. Work to ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham Children’s Hospital is in progress. Configuration to the Children’s Hospital is scheduled for completion by mid-June. A request for configuration work was submitted to IT colleagues at Heartlands in May 2016 and once approved it will take approximately two weeks to allow for firewall configuration and testing. These configurations will be a fixed point in our Managed Equipment Service specification.”

Source location
2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Page 1 · response
Published 19 April 2016
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 all radiographers in the Image Exchange Portal and Image Link, with documented competency sign-off.

Verbatim wording from the response
“3. Training – all radiographers (seventy members of staff who work various shift patterns) are being trained in IEP and Image Link, with a documented process for competency sign-off. Training commenced in June 2016 with a planned completion by the end of September 2016.”

Source location
2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Page 2 · response
Published 19 April 2016
Open published response
22 Feb2016
Surrey
Concerns raised1
1. Delays and restricted access in obtaining urgent CT scans
This report raised 5 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 2
1. Action
  Provide revised out-of-hours CT-requesting guidance in full and abbreviated forms on the intranet and through junior-doctor induction.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
2. Action
  Remove routine Medica-radiologist discussion or direct consultant involvement for specified urgent CT pathways, while retaining radiologist discussion for other out-of-hours scans.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
AI-generated summary

Clifford Irwin Crofts · 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

Clifford Irwin Crofts, who had Parkinson’s disease and aspiration difficulties, was admitted to hospital and underwent insertion of a radiologically inserted gastrostomy tube on 19 September 2014. He experienced acute pain after feeding began, but there were delays in escalating his care, obtaining a CT scan and carrying out surgery; he subsequently developed respiratory difficulties and died on 10 October 2014. The substantive concerns included failure to follow the RIG care plan, difficulties escalating care, delays in obtaining urgent CT imaging, and weekend staffing 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
Delays and restricted access in obtaining urgent CT scans
Wider context from the report
“(3) There were considerable difficulties obtaining a CT scan on Sunday, 21 September 2014. This was partly because it was not actioned at 16.00, when requested. After 17.00 on the weekend the request had to be made by a consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis. The SI report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access. I was informed this has not yet been actioned. ”
Source location
Clifford Irwin Crofts · 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
Provide revised out-of-hours CT-requesting guidance in full and abbreviated forms on the intranet and through junior-doctor induction.

Verbatim wording from the response
“• There is a revised guidance document available for doctors who request CT scanning out of hours (Mon – Fri 20:00 to 08:00 and Sat, Sun & Bank holidays 17:00 to 09:00).”

Source location
Clifford-CROFTS-Response
Page 2 · response
Published 22 February 2016
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
Remove routine Medica-radiologist discussion or direct consultant involvement for specified urgent CT pathways, while retaining radiologist discussion for other out-of-hours scans.

Verbatim wording from the response
“• Scans for patients on the following pathways no longer require a discussion with the Medica radiologist”

Source location
Clifford-CROFTS-Response
Page 2 · response
Published 22 February 2016
Open published response
12 Feb2016
North West Kent
Concerns raised1
1. Lack of a specific application procedure for urgent CT scans
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.
Respondent positions 1
1. Position
  Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.
  Stated by Maidstone and Tunbridge Wells NHS TrustExisting arrangements considered sufficient
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 a specific application procedure for urgent 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
Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.

Verbatim wording from the response
“Without rehearsing my response, I am happy to assure you that there is sound reasoning behind our procedure. Patients fall under the care of consultants, but spend more time being actively treated by junior doctors. To ensure that patients are appropriately escalated for treatment of a worsening condition (in the full knowledge of the treating consultant) it is necessary to ensure that a consultant is aware when a patient is to be sent for a CT scan at all times. On weekdays when consultants are more readily available on-site within the Trust these referrals are less noticeable than out of hours or on weekends, but the procedure is always in place.”

Source location
sandra-wood-Response
Page 2 · response
Published 12 February 2016
Open published response
5 Feb2016
Bedfordshire and Luton
Concerns raised1
1. Lack of a robust system for carrying out urgent tests and imaging without delay at weekends
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 13
1. Action
  Provide 24/7 on-site or on-call plain-X-ray radiography.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
2. Action
  Provide routine weekend CT lists and 24/7 on-call CT access, including consultant and radiologist escalation.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
3. Action
  Provide ultrasound imaging through on-call consultant and radiologist discussion, seven days a week year-round.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
1. Action
  Provide seven-day MRI access, on-call radiologist advice, and specialist-centre transfer when emergency out-of-hours MRI is unavailable.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
2. Action
  Enable requests for fluoroscopy and special procedures through on-call consultant and radiologist discussion.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
3. Action
  Maintain electronic radiology reporting and image availability.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
4. Action
  Introduce and roll out online electronic requesting for radiological examinations, with training.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated planned
5. Action
  Publicise imaging service details and requesting arrangements on the Trust intranet.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
6. Action
  Keep the laboratory open and staffed continuously for specimen testing.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
7. Action
  Provide expanded endoscopy services from 8am to 8pm, seven days a week, following department refurbishment and extension.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
8. Action
  Use an electronic medical handover sheet to highlight outstanding tests and results for follow-up at shift changes.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
9. Action
  Audit the electronic medical handover process as part of the serious-incident action plan.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
10. Action
  Include investigation-service details and access arrangements in new doctor locum packs available on the Trust intranet.
  Stated by Bedfordshire Hospitals NHS Foundation TrustStated completed
AI-generated summary

David MOSTARI · 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

David MOSTARI was admitted to Bedford Hospital on 8 August 2015 with a suspected flare-up of ulcerative colitis, deteriorated, and was found to have a perforated colon with widespread faecal contamination. He died on 10 August 2015 after treatment was withdrawn. The concerns included delays in carrying out urgent imaging following his weekend admission and failures to recognise the seriousness of his condition and take necessary treatment steps.

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 a robust system for carrying out urgent tests and imaging without delay at weekends
Wider context from the report
“1. Mr. Mostari was admitted to the Hospital on a Saturday and despite the need for an urgent x-ray and ultra sound scan the tests were not in fact carried out until the Monday. There therefore does not appear to be any robust system in place for ensuring that urgent tests and imaging are carried out without delay, particularly when a patient is admitted at the week-end. The deceased needed the tests and follow up treatment as a matter of urgency. ”
Source location
David MOSTARI · 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
Provide 24/7 on-site or on-call plain-X-ray radiography.

Verbatim wording from the response
“Imaging”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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 routine weekend CT lists and 24/7 on-call CT access, including consultant and radiologist escalation.

Verbatim wording from the response
“CT scanning”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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 ultrasound imaging through on-call consultant and radiologist discussion, seven days a week year-round.

Verbatim wording from the response
“Ultrasound imaging”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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 seven-day MRI access, on-call radiologist advice, and specialist-centre transfer when emergency out-of-hours MRI is unavailable.

Verbatim wording from the response
“MRI Imaging”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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
Enable requests for fluoroscopy and special procedures through on-call consultant and radiologist discussion.

Verbatim wording from the response
“Fluoroscopy, Special procedures (e.g. Barium enema, nephrostomy), Requests can be made via on-call consultant discussion with an on call radiologist for imaging of any patient.”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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
Maintain electronic radiology reporting and image availability.

Verbatim wording from the response
“General Electronic reporting and availability of images has been in place for several years On-line electronic requesting of radiological examinations to be introduced and rolled out in starting in April 2016. Training provided”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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
Introduce and roll out online electronic requesting for radiological examinations, with training.

Verbatim wording from the response
“General Electronic reporting and availability of images has been in place for several years On-line electronic requesting of radiological examinations to be introduced and rolled out in starting in April 2016. Training provided”

Source location
D-Mostari-Response
Page 4 · response
Published 5 February 2016
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
Publicise imaging service details and requesting arrangements on the Trust intranet.

Verbatim wording from the response
“Full details of services available and requesting arrangements now publicised on trust intranet.”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
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
Keep the laboratory open and staffed continuously for specimen testing.

Verbatim wording from the response
“Pathology”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
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 expanded endoscopy services from 8am to 8pm, seven days a week, following department refurbishment and extension.

Verbatim wording from the response
“Endoscopy”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
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
Use an electronic medical handover sheet to highlight outstanding tests and results for follow-up at shift changes.

Verbatim wording from the response
“Medical Handover”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
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 the electronic medical handover process as part of the serious-incident action plan.

Verbatim wording from the response
“Under the Hospital at Night development, an electronic handover sheet has been developed, to highlight outstanding tests/results to doctors on change of shift to ensure that investigations are pursued/ acted on - sample attached.”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
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
Include investigation-service details and access arrangements in new doctor locum packs available on the Trust intranet.

Verbatim wording from the response
“Details of these services and how to access them have since February 2016 been included in the new doctor locum packs available on the Trust’s intranet.”

Source location
D-Mostari-Response
Page 5 · response
Published 5 February 2016
Open published response
22 Dec2015
Inner North London
Concerns raised1
1. Delays in performing and reporting planned CT scans
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

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
28 Sep2015
Manchester West
Concerns raised1
1. Lack of triage procedures for urgent or unexpected significant x-ray findings
This report raised 7 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 4
1. Action
  Review and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progress
2. Action
  Remind staff that Lakeside Unit patients must be treated as inpatients and update CRIS to reflect that status.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Provide weekday hot reporting of x-rays as soon as possible after examination.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
1. Action
  Train reporting radiographers to interpret chest x-rays and expand specialist radiographer reporting capacity.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStatus at response
Respondent positions 2
1. Position
  Hot reporting is not available at weekends because of resource constraints.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustUnable to act
1. Position
  Local providers are responsible for reviewing local systems concerning X-ray reporting, electronic viewing and patient-note recording.
  Stated by Department of Health and Social CareRedirects responsibility
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in reporting CT scans within the Trust’s five-day timescale

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.3

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

Concerns raised2

Failure to follow up ordered urgent investigations

Failure of referral systems to preserve urgent scan appointments when patients change from in-patient to out-patient status

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays in arranging urgent tests and treatment

Concerns raised1

Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans

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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Failure to reliably transmit CT scans between trusts for timely review

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

Actions described in response 3

Respondent positions 3

Actions described in response 4

Respondent positions 2

Actions described in response 6

Respondent positions 5

Actions described in response 4