Recurring concern

Unreliable chest X-ray referral and ordering

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First reported 9 Jun 2014•Latest report 6 Feb 2024

Definition

What this concern includes

Includes failures in the chest X-ray referral and ordering process, including applying referral thresholds, recognising indications, requesting or ordering the investigation, and acting promptly on those decisions.

Not included

Excludes delays or failures limited to performing, interpreting, reviewing or communicating chest X-ray results after the referral or order has been made.
Excludes failures concerning other imaging investigations unless the report explicitly concerns the chest X-ray referral and ordering process.
Excludes generic guideline dissemination, training or documentation deficiencies unless they directly impair chest X-ray referral or ordering.
Excludes the clinical choice of imaging modality after the report does not identify a failure in chest X-ray referral or ordering.

Reports: 3
Individual concerns: 3
Date range: 2014–2024
Stated actions: 3

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.

East Kent Hospitals University NHS Foundation Trust1

Husband of the deceased1

Ringmead Medical Group1

Son of the deceased1

University Hospitals Plymouth 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.

6 Feb2024
Berkshire
Concerns raised1
1. Failure to routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral
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 2
1. Action
  Reinforced clinical guidance to consider chest X-rays for persistent respiratory symptoms, repeated antibiotics and smoking history.
  Stated by Ringmead Medical GroupStated completed
2. Action
  Circulated the chest X-ray assessment information to locum GPs.
  Stated by Ringmead Medical GroupStated completed
Respondent positions 1
1. Position
  A written practice guideline for chest X-ray requests was difficult because the decision requires individual clinical assessment.
  Stated by Ringmead Medical GroupUnable to act
AI-generated summary

Paula Elizabeth ELSLEY · 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

Paula Elizabeth ELSLEY was found unresponsive at home on 28 March 2022 and declared deceased. The inquest concluded that she was suffering from undiagnosed lung cancer with a metastatic brain tumour, which led to an abscess that caused her death. Concerns included smoking status not being readily accessible in GP records and NICE guidance on chest X-ray referral thresholds not being routinely considered or formally embedded in practice.

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 routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral
Wider context from the report
“2. Thresholds for referral for a chest xray Based on evidence heard at inquest I am concerned that at the time of Paula's death (March 2022) the same NICE guideline was not being routinely considered by GPs. I was very pleased to hear that the practice subsequently introduced their own internal tool for complying if the threshold for a chest x-ray had been reached and that this has been discussed at GP and partner meetings. However some 22 months have now elapsed since Paula's death and no formal policy has been prepared. I remain concerned that the risk of the guideline not being considered remains whilst the change is procedure is informal, especially when it needs to be disseminated to new or locum GPs and other healthcare professionals such as nurses, paramedics and physician associates. ”
Source location
Paula Elizabeth ELSLEY · 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
Reinforced clinical guidance to consider chest X-rays for persistent respiratory symptoms, repeated antibiotics and smoking history.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
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
Circulated the chest X-ray assessment information to locum GPs.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
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 written practice guideline for chest X-ray requests was difficult because the decision requires individual clinical assessment.

Verbatim wording from the response
“The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest X ray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms.”

Source location
Response from Ringmead Medical Group
Page 1 · response
Published 4 July 2024
Open published response
21 Aug2014
Central and South East Kent
Concerns raised1
1. Failure to request a chest X-ray before aspiration
This report raised 8 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

Herbert Chandler · 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

Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

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 request a chest X-ray before aspiration
Wider context from the report
“A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”
Source location
Herbert Chandler · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Jun2014
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to order an indicated chest X-ray promptly on emergency department admission
This report raised 4 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 1
1. Action
  Radiograph patients with chest pain during transfer from the Emergency Department to the MAU.
  Stated by University Hospitals Plymouth NHS TrustStated completed
AI-generated summary

Audrey Christine DAWS · 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

Audrey Christine Daws was admitted to Derriford Hospital with chest pain and other symptoms, but her chest X-ray was delayed and its result was not identified promptly. The X-ray eventually showed air under the diaphragm indicating a perforation; she underwent surgery, deteriorated and died. The principal concerns were inadequate handover of outstanding investigations and delays in ordering, performing and reviewing the X-ray.

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 order an indicated chest X-ray promptly on emergency department admission
Wider context from the report
“2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department. One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue. Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred. ”
Source location
Audrey Christine DAWS · 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
Radiograph patients with chest pain during transfer from the Emergency Department to the MAU.

Verbatim wording from the response
“• All patients with chest pain are now radiographed on the way to the MAU, rather than the test being requested on the MAU and the patient having to return to the Emergency Department for the test.”

Source location
2014-0318-Plymouth-Hospital-NHS-Trust
Page 2 · response
Published 9 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to routinely apply and formally disseminate the NICE guideline thresholds for chest x-ray referral

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to request a chest X-ray before aspiration

Concerns raised1

Failure to order an indicated chest X-ray promptly on emergency department admission

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.1

Actions described in response 2

Respondent positions 1

Actions described in response 1