Recurring concern

Unreliable transfer of diagnostic images between healthcare organisations

First to latest report 12 Feb 2014 — 5 Mar 2024

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
5

What this concern includes

Includes failures in arrangements for transferring, receiving, accessing or reliably using diagnostic images between healthcare organisations, including missing backup or contingency arrangements and failures to implement guidance governing receipt and reporting of images from external organisations.

What is not included
  • Excludes failures limited to interpretation of images after the images are reliably available to the responsible clinicians.
  • Excludes radiology reporting, result communication or follow-up failures where the diagnostic images themselves were transferred and accessible.
  • Excludes generic electronic-record, IT or information-sharing deficiencies unless they directly impair transfer or access to diagnostic images between healthcare organisations.
  • Excludes image-transfer failures unrelated to healthcare diagnosis or patient care.

Reports and published responses 5 reports

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

  1. Mid Kent and Medway

    AI-generated summary

    Kerri Louise Mothersole · 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

    Kerri Louise Mothersole, a 44-year-old woman, died on 20 August 2022 after developing endometrial cancer with brain metastases. Her diagnosis was delayed, including because an earlier ultrasound report and associated images were not provided to treating clinicians or uploaded to hospital clinical notes, and community imaging was not available on the central imaging system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to make private-provider imaging available through the central imaging system

    Wider context from the report

    “(1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage. (2) The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance. (3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths. ”

    Source location

    Kerri Louise Mothersole · 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

    Continue transitioning providers from individual PACS systems to a central PACS system, including integration of acute provider trusts.

    Verbatim wording from the response

    “To address the concerns highlighted in the Regulation 28 Report, we can confirm that Kent and Medway have been moving away from individual PACS systems resident in each of our providers to a central PACS system. Procurement commenced in 2021, with the integration of acute provider trusts in September 2023.”

    Source location

    Response from Kent and Medway
    Page 2 · response
    Published 14 March 2024

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    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 the incident and diagnostic workflow, audit data-sharing systems, and produce and assess an options appraisal for process and IT integration improvements.

    Verbatim wording from the response

    “2. To provide longer term assurance, and in acknowledgment of this matter, NHS Kent and Medway will examine potential changes where appropriate relating to IT integration. To support this, we will undertake a review of how the incident occurred and determine how the risk of this re-occurring can be reduced. This will include:”

    Source location

    Response from Kent and Medway
    Page 3 · response
    Published 14 March 2024

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    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

    GPs receive community diagnostic reports, assess them clinically, and decide whether referral to secondary care is required.

    Verbatim wording from the response

    “Community diagnostics were introduced in the 2010s to improve access and reduce cost. However, no work was commissioned at the time to provide integration to GP or acute systems. The standard protocol is for community diagnostic providers to send reports (text-based), as opposed to the full diagnostics image, back to the GP that requested the investigation. The GP will then assess the report in the context of their holistic assessment of the patient and they make a clinical decision on whether to refer a patient to secondary care.”

    Source location

    Response from Kent and Medway
    Page 2 · response
    Published 14 March 2024

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Lee Dryden · 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 Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.

    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 by NHS Trusts to understand and embed image-reporting guidance

    Wider context from the report

    “1. There is Royal College Guidance as to how and by what means the images are reported from external organisations such as Medical Alliance to NHS Trusts however this appears to not be understood or embedded by NHS Trusts. ”

    Source location

    Lee Dryden · 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

    Host a national webinar and make imaging-report notification guidance available to NHS staff through the Futures platform.

    Verbatim wording from the response

    “• NHS England hosted a national webinar on 7th March 2023 with the inclusion of the above delivered by the RCR for NHS services. This guidance is also available on the NHS England Futures website, a virtual collaboration platform for NHS staff members to make change, improve and transform health and social care.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 August 2025

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    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

    Highlight fail-safe imaging-report notification recommendations and related investigation findings in the national Patient Safety bulletin.

    Verbatim wording from the response

    “• The Academy of Medical Royal Colleges (AoMRC) published a report on ‘Alerts and notification of imaging reports – Recommendations’ which include recommendations on fail-safe notification systems. This was highlighted by NHS England in the January 2023 national Patient Safety bulletin and followed a report from the Healthcare Safety Investigation Branch (HSIB): Failures in communication or follow-up of unexpected significant radiological findings.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 August 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

    Seek assurance from regional systems that national imaging-reporting guidance is being followed.

    Verbatim wording from the response

    “My North East & Yorkshire (NEY) regional colleagues have also advised that they have gone out to all NEY systems for assurance that national guidance is being followed around image reporting. Systems bring together NHS organisations, local authorities and others to take collective responsibility for health and care planning services across geographical areas.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 August 2025

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    Sharon Jamela Reeve · 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

    Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

    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

    Slow image-transfer conduit preventing review of CT and MRI images

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Patrick Clifford · 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

    Patrick Clifford fell in a hospital toilet after fainting on 19 March 2016 and suffered a fractured acetabulum. His condition deteriorated, and he developed pneumonia due to immobility and heart failure before dying on 18 September 2016. The principal concerns were inadequate understanding of toilet supervision, difficulties transferring radiology images between hospitals, and refusal to undertake requested Judet X-rays, causing delays to treatment.

    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

    Difficulties in transferring and accessing radiology images and reports between hospitals

    Wider context from the report

    “2. The evidence from the clinicians was that there were sometimes difficulties in transferring images to other hospitals. In this case there appeared to be misunderstandings as to whether or not Wrightington could access radiology images/reports through the Royal Blackburn Hospital PACS system and vice-versa. In the present case this caused delays in the commencement of necessary physiotherapy treatment and I am concerned that future delays could similarly delay treatment and risk future deaths as a result. ”

    Source location

    Patrick Clifford · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Georgina Violet SWINDELLS · 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

    Georgina Violet Swindells underwent a right hemicolectomy for colon cancer and subsequently developed persistent hypotension and haemorrhage, dying on 18 September 2013. Concerns included delayed and failed transfer of CT images, the absence of an effective backup process, apparently erroneous reporting of the scan, and insufficient investigation data and incident reporting.

    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 implement the image transfer backup system

    Wider context from the report

    “(4) The backup system in place (i.e. an on-call radiologist who can attend the hospital) appears not to have been implemented on this occasion. Again, the cause for this is unclear and I have concerns that the systems in place are not sufficiently robust; ”

    Source location

    Georgina Violet SWINDELLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026