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

Distinct published reports

Individual concerns
27

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
66

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.

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.

  1. Hampshire, Portsmouth Southampton

    AI-generated summary

    Shre Kumar CHATTERJEE · 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

    Shre Chatterjee developed a sudden severe headache in August 2023 and died at University Hospital Southampton on 12 October 2023 from an acute on chronic subdural haematoma. The report identifies repeated unsuccessful attempts to obtain timely face-to-face medical assessment, including missed opportunities to refer him for hospital assessment and a CT scan. It also raises concern that out-of-hours and 111 doctors could not directly book urgent appointments with some GP surgeries.

    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

    Unavailability of blood tests and imaging in Urgent Care Centres

    Wider context from the report

    “During the Course of the Inquest it became clear that whilst OOH/111 Doctors should be able to access direct booking with a patient's own GP in cases requiring a face to face assessment ,this facility is being blocked by some GP surgeries. This means that if a patient requires an urgent assessment the OOH Doctor can only refer them to contact the GP surgery. or direct to an Urgent Care Centre which is supposed to treat minor injuries and where they may still not be examined by a Dr, and blood tests imaging are not available. In the deceased's case despite numerous attempts to access a GP appointment he did not actually see a Doctor from 23rd August 2023 until he was eventually admitted to hospital with a then fatal brain bleed on 10th October 2023. It was agreed by witnesses that if a Dr had seen the deceased face to face sooner , particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived. ”

    Source location

    Shre Kumar CHATTERJEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. South Yorkshire (Eastern)

    AI-generated summary

    Lee James STAMMERS · 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

    Lee Stammers attended Doncaster Royal Infirmary on 10 February 2025 with chest pain, shortness of breath and nausea, suffered a cardiorespiratory arrest later that day, and was pronounced deceased at 20:00 hours. The report identified missed opportunities to detect myocardial ischaemia, including incomplete or unreported electrocardiography and blood tests not being performed. Concerns also included poor documentation, communication and systems for tracking investigations, and the ability of unidentified staff to cancel tests without rationale or accountability.

    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 maintain accurate medical records and communicate information needed for urgent tests

    Wider context from the report

    “(1) Poor documentation, Communication, and systems– There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained. Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram. Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians, who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records. These individuals were referred to as “unknown” at the inquest and have not been identified. Finally, there was clear and consistent evidence of poor documentation throughout the medical records, from admission to the emergency department continuing through to the resuscitation attempts. ”

    Source location

    Lee James STAMMERS · 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

    Implement the identified communication and documentation immediate safety actions in the Emergency Department under senior-doctor oversight.

    Verbatim wording from the response

    “Mr Stammers’ case was formally presented to the Learning from Patient Safety Events (LFPSE) Panel with the declaration of a Patient Safety Incident Investigation (PSII). During this meeting, Immediate Safety Actions were identified and shared with the relevant division to ensure prompt implementation.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and implement a chest-pain standing operating procedure defining required clinical assessment and investigations in the Emergency Department.

    Verbatim wording from the response

    “Safety Recommendation 2 - The ED should develop Standing Operating Procedure (SOP) to ensure standardised care within the ED when patients present with chest pain. This should include expectations of the clinical assessment and investigation required. Once implemented, this should be followed by education and training for all ED staff.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 1 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce a local Emergency Department quality-improvement initiative focused on communication and contemporaneous documentation.

    Verbatim wording from the response

    “Safety Recommendation 4 – The ED to introduce a local quality improvement initiative focusing on enhancing communication and contemporaneous documentation in both emergency and non-emergency situations.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 3 · response
    Published 1 September 2025

    Open published response
  3. East London

    AI-generated summary

    Abdirahman Afrah · 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

    Abdirahman Afrah developed severe chest pain and attended A&E, but left without being seen by a doctor after a prolonged wait. He later collapsed at home and died in hospital on 4 June 2024 from bleeding caused by a pulmonary vascular malformation. The concerns included prolonged A&E waits, lack of timely medical triage, unclear communication about the urgency of returning to hospital, failure to discuss this directly with a responsible parent, and failure to send results to his GP in time.

    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 commence appropriate investigations at an early stage

    Wider context from the report

    “2. There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage. Without such frontloading of care, patients like Abdirahman who might compensate right up to the point of collapse, might be missed again. ”

    Source location

    Abdirahman Afrah · 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

    Add enhanced rapid assessment training to resident doctor induction.

    Verbatim wording from the response

    “Since August 2024, enhanced RAT training has been added to the induction of all resident doctors above foundation level and there is an active program to train all regular locum doctors in this process. This has increased our capacity to front-load tests and investigations throughout the day and night.”

    Source location

    2025-0245- Response from Barts Health NHS Foundation Trust
    Page 2 · response
    Published 29 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train regular locum doctors in rapid assessment and treatment.

    Verbatim wording from the response

    “Since August 2024, enhanced RAT training has been added to the induction of all resident doctors above foundation level and there is an active program to train all regular locum doctors in this process. This has increased our capacity to front-load tests and investigations throughout the day and night.”

    Source location

    2025-0245- Response from Barts Health NHS Foundation Trust
    Page 2 · response
    Published 29 May 2025

    Open published response
  4. Cambridgeshire and Peterborough

    AI-generated summary

    Chantelle Reed · 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

    Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after 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 Radiologist review of emergency chest x-rays

    Wider context from the report

    “2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists. The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died. In an emergency situation such as this one, this delay represents on ongoing risk of future deaths. ”

    Source location

    Chantelle Reed · 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

    Publish national image-report turnaround-time guidance, including a four-hour maximum for acutely unwell A&E patients during routine hours.

    Verbatim wording from the response

    “NHS England published the Image report turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from acquisition to image reports, with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E) during routine hours of working.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 26 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Support Trusts to increase radiology reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.

    Verbatim wording from the response

    “The guidance includes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 26 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the NHS Long Term Workforce Plan to train, retain and reform healthcare staff across the NHS over fifteen years.

    Verbatim wording from the response

    “In June 2023, NHS England also published the NHS Long Term Workforce Plan, in response to the current lack of sufficient workforce. The plan sets out how we will train, retain and reform healthcare staff across the NHS over the next fifteen years, and is underpinned by the biggest recruitment drive in NHS history.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 26 September 2023

    Open published response
  5. Manchester South

    AI-generated summary

    Marianne Erika Oldham · 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

    Marianne Erika Oldham was admitted to Tameside General Hospital with vomiting and abdominal pain and was diagnosed with a perforated sigmoid colon after a prolonged delay in clinical assessment and imaging. She deteriorated, was treated conservatively, and died from peritonitis. The report identified concerns about delays linked to Emergency Department demand, staffing shortages, and shortages of radiographers and radiologists.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Shortage of radiographers and radiologists causing delays in scan performance and reporting

    Wider context from the report

    “The inquest heard evidence that the very significant delay for Mrs Oldham to be seen by a clinician was due to the demand on Emergency Department Services. The inquest was told that delays of this length (9 hours) for patients who had been triaged to be seen within 60 minutes were not uncommon throughout the winter period across Greater Manchester and more widely. The demand was due to the volume of patients and the number of staff available to see and treat them. The delay was compounded by the shortage of radiographers and radiologists nationally meaning that even when a decision is taken for a scan it can take some time (9 an hour in this case) for it to take place and then reported on. In the time that Mrs Oldham was waiting to be seen she deteriorated very significantly meaning that by the time it was understood what the issue was she was very unwell and did not respond to conservative treatment which was all she was well enough for by that point. ”

    Source location

    Marianne Erika Oldham · 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

    Implement the Long Term Workforce Plan to improve training, staff retention, workforce reform and sustainable staffing.

    Verbatim wording from the response

    “Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS Trusts are responsible for ensuring appropriate staffing, senior clinical support and diagnostic provision for anticipated demand.

    Verbatim wording from the response

    “Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 28 July 2023

    Open published response
  6. West Yorkshire Eastern

    AI-generated summary

    Carol Ann Hatch · 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

    Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her 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 urgent diagnostic imaging for patients displaying septic shock symptoms

    Wider context from the report

    “8. When the surgeon sought an x ray at 8.35 am there was a delay until this took place at 10.09 am. There was a failure to appreciate the urgency of the situation in a patient who was displaying symptoms of septic shock. ”

    Source location

    Carol Ann Hatch · 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

    Delays in urgent blood sample delivery and reporting

    Wider context from the report

    “10. Blood samples taken at 8.02 am were not delivered to the laboratory until 9.06 am and then not reported on until 10.21 am as they had not been marked as ‘urgent’. This also reflects a failure to appreciate the gravity of the situation. ”

    Source location

    Carol Ann Hatch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Manchester South

    AI-generated summary

    Oliver Christopher Lindsay · 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

    Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.

    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 providing urgently required fetal growth scans

    Wider context from the report

    “1. At his mother’s midwife check-up, it was identified that Oliver may have fetal growth restriction and that a scan was urgently required. A referral was made to the acute trust. However scanning capacity issues meant that there was a delay in an appointment being offered. Oliver’s parents were very concerned and felt they had no choice but to pay to have a private scan which did confirm fetal growth restriction and resulted in his mother attending the acute trust to be seen. The inquest heard evidence that there were capacity issues in relation to growth scans nationally particularly after a bank holiday or a weekend. ”

    Source location

    Oliver Christopher Lindsay · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Mid Kent and Medway

    AI-generated summary

    Johanna Marie MORELAND · 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

    Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.

    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 making lumbar puncture results available

    Wider context from the report

    “(1) Results from lumbar puncture taken on 26th February 2021 were made available on 4th March 2021. Evidence heard at the inquest was that Lumbar Puncture tests are usually for diagnosis of serious illness and would usually be made available within 24-48 hours. (2) The Lumbar Puncture results were positive for encephalitis and in the absence of the tests results, a liver biopsy was conducted and, there was a delay in antiviral treatment commencing. ”

    Source location

    Johanna Marie MORELAND · 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

    The viral lumbar puncture results were received within the normal turnaround time for this outsourced investigation.

    Verbatim wording from the response

    “The Trust has investigated the timeframe for the availability of Mrs Moreland’s results. The cerebrospinal fluid (CSF) sample was taken on Friday 26th February 2021 and was received at the Pathology department at 17:28 on the same evening. The standard cell count, protein and glucose levels and bacterial screening and culture, performed in our microbiology laboratory at North Kent Pathology Services based at Dartford, was available within normal turnaround time of 24-48hrs and was unremarkable.”

    Source location

    2021-0240-Response-from-Medway-Maritime-Hospital_Published
    Page 2 · response
    Published 15 July 2021

    Open published response
  9. Lancashire and Blackburn with Darwen

    AI-generated summary

    Mr Frank Charles Medley · 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 Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

    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

    Inappropriate and undocumented prioritisation of urgent MRI scans

    Wider context from the report

    “(2) The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest. b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance; c. The case was inappropriately allocated to a structured judgement review; d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading; e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor"; iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust); iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest; v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event. f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan; g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services; h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG; i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation; j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day. k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need; l. There was insufficient senior clinical oversight of the conclusions drawn. ”

    Source location

    Mr Frank Charles Medley · 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

    Review inpatient radiology priorities at vetting stage and align time-based priorities with NICE guidance where applicable.

    Verbatim wording from the response

    “We are currently also reviewing the In-patient priorities applied at vetting stage by Radiology. It is anticipated that these will be time-based allowing a better understanding of the priority applied at vetting; aligned to NICE guidance for urgent imaging where stated. This will allow pressures within the system to be escalated so that clinical decisions can be made on how best to proceed.”

    Source location

    2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
    Page 5 · response
    Published 8 March 2021

    Open published response
  10. Shropshire, Telford and Wrekin

    AI-generated summary

    Peter Edward SMITH · 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

    Peter Edward SMITH died on 4 March 2019 after relapsing on 20 February 2019. The report identified significant delay in the diagnosis and treatment of his adenocarcinoma, with tests, reports, appointments and discussions taking place consecutively so that surgery was no longer possible by the scheduled date.

    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 diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions

    Wider context from the report

    “1. There was significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which contributed to his death on the 4th March 2019. 2. Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible. 3. Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did. ”

    Source location

    Peter Edward SMITH · 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 standard operating procedure for referring suspected or confirmed lung cancer patients for surgical resection.

    Verbatim wording from the response

    “The Trust and the teams involved recognise the delays in this case and have reviewed their pathways and processes. From November 2019, the Trust has updated their Standard Operating Procedure (SOP) which provides advice on the referral of patients for surgical resection of proven or suspected lung cancer to prevent delays. This covers the following areas:”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 1 · response
    Published 8 February 2020

    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

    Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.

    Verbatim wording from the response

    “From November 2019, the Trust has streamlined the diagnostic pathway (enclosed at Appendix 2) for patients being investigated for potential lung cancer which involved collaboration with Clinical Commissioning Group’s regarding ‘direct to CT’ pathways and to the urgent ‘hot-reporting’ of chest x-”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 1 · response
    Published 8 February 2020

    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

    Implement and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.

    Verbatim wording from the response

    “Improvement work has been undertaken and evaluated with regards to developing diagnostic ‘bundles’ of tests to streamline investigations and agree which investigations are appropriate for specific patient groups, recognising that each investigation involves a potential delay, but that it is important to ensure that a patient is risk assessed appropriately prior to listing for surgical intervention.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Flag concerning abnormal chest X-rays to the Lung Cancer Team daily.

    Verbatim wording from the response

    “• Every chest x-ray with an abnormality which is concerning for a potential lung cancer is now flagged up to the Lung Cancer Team on a daily basis. Although, in the case of Mr Smith, his initial x-ray had been reported as normal as the changes were subtle.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Triage CT results daily after abnormal chest X-rays raise possible lung cancer, alerting the Lung Cancer Team and responsible consultant.

    Verbatim wording from the response

    “• There is daily triage of CT scan results performed following receipt of an abnormal chest x-ray where the potential for lung cancer has been raised by the reporting radiologist. It has been established that had this been the case for Mr Smith, this may have reduced the timescale between radiology reporting and receipt of that report by the requesting clinician by six days. This would also trigger the Lung Cancer Team and alert the patient’s Consultant.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.

    Verbatim wording from the response

    “• The request of additional tests can result in further delays: the Trust’s new protocol has standardised the pre-operative assessment process to try and minimise clinically unnecessary tests, recognising that each additional test builds in a potential time delay.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Allow PET scans to be requested before multidisciplinary discussion, requiring discussion after the PET-CT result.

    Verbatim wording from the response

    “• Patient’s cases do not need to be discussed at an MDT meeting in order to facilitate the requesting of a PET scan, but only following receipt of the PET CT result.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Increase surgical clinical capacity to prevent delays in clinic appointments.

    Verbatim wording from the response

    “• There has been an increase in surgical clinical capacity, preventing delays for clinic appointments.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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 coordinated lung cancer working arrangements with UHNM, including weekly thoracic surgical outpatient clinics and multidisciplinary team attendance.

    Verbatim wording from the response

    “The Shrewsbury and Telford Hospital NHS Trust and UHNM continue to maintain close links and working closely together in the diagnosis and treatment of lung cancer patients. UHNM cardiothoracic surgeons attend SaTH weekly to operate surgical outpatient clinics and to attend weekly MDT meetings in person.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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 quality improvement work towards compliance with the National Optimal Lung Cancer Pathway.

    Verbatim wording from the response

    “All improvements have also supported the Trust in quality improvement to work towards compliance with the National Optimal Lung Cancer Pathway which is due to come into practice by April 2020.”

    Source location

    2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
    Page 2 · response
    Published 8 February 2020

    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

    Agree a standard operating procedure for referrals for surgical resection of proven or suspected lung cancer.

    Verbatim wording from the response

    “With regard to the delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma SaTH has produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached Standard Operating Procedure [SOP] – “Referral for surgical resection of proven or suspected lung cancer”. SaTH has implemented the SOP and will be responding to you separately.”

    Source location

    2020-0022-Response-from.-UNMH
    Page 2 · response
    Published 8 February 2020

    Open published response
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Data last updated 7 September 2026