22 Dec 2025 Winifred Mary Wardle · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Absence of a clear multidisciplinary protocol for CT scan requests View source Failure to ensure clear and understood escalation routes for rejected CT scan requests View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Winifred Mary Wardle · 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
Winifred Mary Wardle was admitted to hospital with vomiting and an undiagnosed intestinal problem; an incarcerated hernia was identified by CT scan after delays in obtaining the scan. She underwent surgery, aspirated stomach contents immediately beforehand, developed pneumonia, and died after active treatment was withdrawn. The substantive concerns related to the lack of a clear multidisciplinary protocol for CT scan requests, radiology decision-making and escalation processes, and incomplete records of those decisions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a clear multidisciplinary protocol for CT scan requests
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests ;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
” Source location Winifred Mary Wardle · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure clear and understood escalation routes for rejected CT scan requests
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants ; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
” Source location Winifred Mary Wardle · Prevention of Future Deaths report
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23 Apr 2025 Lorraine Sandra Parker · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Lorraine Sandra Parker · 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
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing , as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise . Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan.
” Source location Lorraine Sandra Parker · Prevention of Future Deaths report
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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 Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Verbatim wording from the response “The NICE guideline does not provide detailed protocols for postoperative tests or scans, and clinicians would be expected to use their judgement and follow local protocols or other relevant professional guidance. However, whilst the Department has no immediate plans to instruct NICE to produce standalone guidance on post-surgery imaging based on CRP thresholds, details of this case have been shared with colleagues in NICE’s prioritisation team to consider if further action should be taken.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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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 ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical guidance is primarily the responsibility of NICE and relevant Royal Colleges, while Trusts should implement appropriate local processes or guidance.
Verbatim wording from the response “While NHS England notes your concerns, clinical guidelines are primarily the responsibility of the National Institute for Health and Care Excellence (NICE) and the appropriate Royal Colleges. NHS Trusts are expected to have due regard to any clinical guidelines and to implement the appropriate local processes and/or guidance. I note that you have also addressed your Report to the Association of Coloproctology of Great Britain (ACPGBI) and the Royal College of Surgeons, who are the more appropriate organisations to respond to your concerns.” Source location Response from NHS England
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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 Further guidance on CT scanning after abdominal surgery with raised CRP is not required because existing guidance and evidence address anastomotic leaks.
Verbatim wording from the response “NHS England has however discussed your Report with the ACPGBI, and it is agreed that there is not a requirement for further guidance to be written. CRP levels are” Source location Response from NHS England
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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 Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Verbatim wording from the response “With regard to concerns about guidance for clinicians, the NICE guideline on colorectal cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer by providing evidence-based recommendations on the management of both local disease and metastatic (secondary) cancer. It covers which interventions should be used for different types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and other treatments.” Source location Response from DHSC
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29 Dec 2023 Karmchand Gulzar · Prevention of Future Deaths report Black Country
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Concerns raised 1
Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Karmchand Gulzar · 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
Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations
Wider context from the report “(2) No CT scan was undertaken as required by the acute abdominal pathway and guidance as part of the initial assessment. I was concerned by evidence that a CT scan would not be undertaken urgently as part of an acute abdominal presentation and that the necessity for a scan may not be known by junior (or some consultant) doctors .
” Source location Karmchand Gulzar · Prevention of Future Deaths report
Open source report
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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 Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.
Verbatim wording from the response “The Management of Acute Abdomen guideline that was in use at the time of this incident has been updated and re-issued in June 2023. This guideline was created in consultation with the Doctors working within the Emergency Department and the Patient Safety team, to ensure the appropriate learning is incorporated into the process. The guideline aligns with the BMJ Best Practice recommendations.” Source location Response from Sandwell and West Birmingham NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.
Verbatim wording from the response “In order to embed the new guideline, it has been sent to all applicable staff, published on our intranet site and discussed within team meetings and appropriate forums. The guidance is highlighted at induction sessions for new doctors and in appropriate teaching sessions. Staff have also been reminded to include outstanding referrals at the handover discussion. Mr Gulzar’s case has also been anonymised and discussed with the clinical teams within the Emergency and” Source location Response from Sandwell and West Birmingham NHS Trust
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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 acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.
Verbatim wording from the response “Surgical departments to ensure our teams are aware of the learning from this case. To assess the efficacy of the activities described above, an audit of the Acute Abdomen pathway is planned in March 2024.” Source location Response from Sandwell and West Birmingham NHS Trust
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28 Jun 2023 Hilary THOMAS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to follow guidance on proceeding with CT scans without waiting for blood test results View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
University Hospitals Birmingham NHS Foundation Trust
Display laminated posters explaining the emergency contrast CT guidance in acute surgical areas at all acute sites by 31 October 2023.
View source
University Hospitals Birmingham NHS Foundation Trust
Publish and disseminate a Trust policy reflecting the June 2023 emergency contrast CT guidance to all clinical staff by 31 October 2023.
View source
University Hospitals Birmingham NHS Foundation Trust
Update the online requesting system to reflect the emergency contrast CT guidance by 31 October 2023.
View source
University Hospitals Birmingham NHS Foundation Trust
Discuss the emergency contrast CT guidance at relevant departmental governance meetings by 31 October 2023.
View source See 1 more action
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Hilary THOMAS · 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
Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.
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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 guidance on proceeding with CT scans without waiting for blood test results
Wider context from the report “3. The doctor treating Mrs Thomas on her second attendance decided to wait for blood test result before ordering a CT scan under the misunderstanding that these were required to assess the possibility of renal toxicity from dye used during the scan . The inquest heard evidence that a CT scan should have been undertaken and there was no need to wait for blood test results . This raised a concern that staff at the Trust are unaware of this guidance .
” Source location Hilary THOMAS · Prevention of Future Deaths report
Open source report
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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 Display laminated posters explaining the emergency contrast CT guidance in acute surgical areas at all acute sites by 31 October 2023.
Verbatim wording from the response “Modern contrast agents are much safer than older agents and studies have reported that blood tests are not required for emergency CT scans. In June 2023, the Royal Colleges of Radiologists & Royal College Emergency Medicine published joint guidance, strengthening previous guidance, that patients requiring emergency iodinated intravenous contrast CT imaging should proceed to scanning without delay. The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Publish and disseminate a Trust policy reflecting the June 2023 emergency contrast CT guidance to all clinical staff by 31 October 2023.
Verbatim wording from the response “Modern contrast agents are much safer than older agents and studies have reported that blood tests are not required for emergency CT scans. In June 2023, the Royal Colleges of Radiologists & Royal College Emergency Medicine published joint guidance, strengthening previous guidance, that patients requiring emergency iodinated intravenous contrast CT imaging should proceed to scanning without delay. The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies.” Source location Response University Hospitals Birmingham NHS Foundation Trust
Open published response
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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 Update the online requesting system to reflect the emergency contrast CT guidance by 31 October 2023.
Verbatim wording from the response “1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical staff. The Trust will update online requesting system to reflect the new guidance. This will be discussed at all relevant departmental governance meetings. These actions will be completed by 31st October 2023.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Discuss the emergency contrast CT guidance at relevant departmental governance meetings by 31 October 2023.
Verbatim wording from the response “1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical staff. The Trust will update online requesting system to reflect the new guidance. This will be discussed at all relevant departmental governance meetings. These actions will be completed by 31st October 2023.” Source location Response University Hospitals Birmingham NHS Foundation Trust
Open published response
12 May 2021 MARY ANNE MELLOR · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans View source
Linked responses
Liverpool Heart and Chest Hospital NHS Foundation Trust Medica Reporting Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Liverpool Heart and Chest Hospital NHS Foundation Trust
Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.
View source
Liverpool Heart and Chest Hospital NHS Foundation Trust
Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.
View source
Liverpool Heart and Chest Hospital NHS Foundation Trust
Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.
View source
Medica Reporting Limited
Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.
View source
Medica Reporting Limited
Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.
View source
Medica Reporting Limited
Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.
View source
Medica Reporting Limited
Share learning from this case with reporting radiologists.
View source
Medica Reporting Limited
Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.
View source
Medica Reporting Limited
Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.
View source See 6 more actions
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AI-generated summary
MARY ANNE MELLOR · 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
Mary Anne Mellor died at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent. The leak was not identified on CT scans in 2019 and 2020 because 3D reconstruction was not used. Concern remained that other patients with aortic stents could be at risk of leaks not being identified, potentially depriving them of elective surgical management before life-threatening complications occurred.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Wider context from the report “(1) Following a thorough investigation, I HCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported . LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of the date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future .
(2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur.
” Source location MARY ANNE MELLOR · Prevention of Future Deaths report
Open source report
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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 Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.
Verbatim wording from the response “In order to ensure this event does not reoccur, we have written a formal policy which has been approved and circulated to all relevant clinicians. In it, it states that all images of this nature must be reported using multi planar view.” Source location 2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
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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 Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.
Verbatim wording from the response “In order to ensure this event does not reoccur, we have written a formal policy which has been approved and circulated to all relevant clinicians. In it, it states that all images of this nature must be reported using multi planar view.” Source location 2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
Open published response
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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 Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.
Verbatim wording from the response “Following the meeting held with Medica on the 19th May 2021, it was agreed that LHCH will perform and report in house for this type of image as we are able to store images that demonstrate MPR has been used and they will no longer be outsourced to Medica.” Source location 2021-0153-Response-from-Liverpool-Heart-and-Chest-Hospital-Redacted
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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 Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.
Verbatim wording from the response “2. Medica routinely trains reporters in the use of the Radiology image viewing system (Medica Insignia PACS system) including the use of Multiplanar Reformatting (MPR) for the interpretation and reporting of all cross-sectional imaging (CT and some MRI). MPR is a term used to describe the type of 3D reconstruction that would be used in the case of the deceased.” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.
Verbatim wording from the response “5. In September 2020 Medica prepared an in-house training video which includes a section on MPR (3D) technique. This was notified to all reporting radiologists and placed in the online learning folder There is a training video and Radiology Reporting Process Guide for post training reference available to reporters at all times (Attachments 1.3 Screenshots from training video and 1.4 Radiology Reporting Process Guide).” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.
Verbatim wording from the response “8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Share learning from this case with reporting radiologists.
Verbatim wording from the response “8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.
Verbatim wording from the response “8. Medica continually audits radiologist reporting (5% sample of this type of work for each radiologist) and provides opportunities for learning from error. Medica provides feedback to individual Medica radiologists on a case-by-case basis where errors have been made and will highlight the use of good MPR technique for analysis. Medica regularly highlights areas of opportunity to improve observation and interpretation for reporters. Cases of interest are shared with all reporting radiologists in a monthly review. This case will be shared with our radiologists as an action of the Medica RCA for this case (initiated and completed following notification of the inquest, attachment 1.5).” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.
Verbatim wording from the response “11. It is not possible to monitor/measure the use of MPR tools in a simple or meaningful way but experienced analysis of reporting discrepancies can lead the reviewer to highlight this to reporting radiologists when the reviewer considers that this may be a contributory factor. Medica will as a result of this notice, remind case reviewers of the importance of the use of MPRs.” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 The reporter normally uses MPR tools, so the concern that their use was not assured is disputed.
Verbatim wording from the response “The above items evidence the importance that Medica places upon MPR functionality in CT reporting. The reporter in this case uses MPR in their normal workflow. It is therefore possible that it was employed at the time of reporting this study, but the endoleak was not recognised by the reporter. This is termed an observational error and is a recognised error in radiology. Medica places great importance on informing reporters of errors made by others to maximise learning opportunities and reduce error in the future as much as possible. We will be sharing the learning from this case with our reporters.” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 Existing MPR training, guidance, auditing, refresher training and shared learning address MPR use in CT reporting.
Verbatim wording from the response “2. Medica routinely trains reporters in the use of the Radiology image viewing system (Medica Insignia PACS system) including the use of Multiplanar Reformatting (MPR) for the interpretation and reporting of all cross-sectional imaging (CT and some MRI). MPR is a term used to describe the type of 3D reconstruction that would be used in the case of the deceased.” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
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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 MPR tool use cannot be monitored or measured in a simple or meaningful way.
Verbatim wording from the response “11. It is not possible to monitor/measure the use of MPR tools in a simple or meaningful way but experienced analysis of reporting discrepancies can lead the reviewer to highlight this to reporting radiologists when the reviewer considers that this may be a contributory factor. Medica will as a result of this notice, remind case reviewers of the importance of the use of MPRs.” Source location 2021-0153-Response-from-Medica-Redacted
Open published response
29 Mar 2019 Colin Bailey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Colin Bailey · 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
Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication
Wider context from the report “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used . The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance .
” Source location Colin Bailey · Prevention of Future Deaths report
Open source report
6 Aug 2018 Ms Susan Joan Elliott (Sue) · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1
Lack of documented protocols for treatment and 24/7 CT scanning and reporting View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ms Susan Joan Elliott (Sue) · 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
Ms Susan Joan Elliott died at Sunderland Royal Hospital on 14 September 2017 after a fall, an initially unconfirmed suspected hip fracture, subsequent readmission and surgery. Concerns included that the 4 August x-ray was reportedly ignored, no CT scan was undertaken before discharge, and surgery may have been possible earlier.
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× 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 documented protocols for treatment and 24/7 CT scanning and reporting
Wider context from the report “Reference was made to new protocols about the treatment of patients presenting with similar conditions such as Sue (particularly for 24/7 CT scanning/reporting ), but no documents were produced .
” Source location Ms Susan Joan Elliott (Sue) · Prevention of Future Deaths report
Open source report
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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 Include the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.
Verbatim wording from the response “At the inquest, the same witness also made reference to new protocols about the treatment of patients presenting with similar conditions such as Ms Elliott, but did not produce any documents. I would like to assure you that we do have an “Emergency Department Injured Elderly Non-Wight Bearing (NWGB) Guideline” which was developed in 2015. This guideline provides clear recommendations for cross sectional (CT) imaging and reporting, where pain or dysfunction suggests an occult fracture. I have provided a copy of this guideline.” Source location 2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Open published response
22 Feb 2016 Clifford Irwin Crofts · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Lack of accessible guidance on the process for arranging CT scans View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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× 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 accessible guidance on the process for arranging 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
Open source report
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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 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
Open published response
Concerns raised 1
Inconsistent criteria for requesting CT scans outside standard hours and at weekends View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Betsi Cadwaladr University LHB
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AI-generated summary
Ronald Perry · 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
Ronald Perry attended Glan Clwyd Hospital on 17 January 2014, was discharged after examination, then collapsed several hours later and could not be resuscitated after readmission. Evidence at the inquest indicated that a CT scan might probably have detected his aneurysm, and raised concern about inconsistent criteria for requesting CT scans outside normal hours and at weekends, creating continuing risks to patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent criteria for requesting CT scans outside standard hours and at weekends
Wider context from the report “During the course of the inquest, evidence given by ████████
████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend.
That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths.
” Source location Ronald Perry · Prevention of Future Deaths report
Open source report
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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 Existing emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.
Verbatim wording from the response “The Radiology service at all three district general hospital’s in North Wales operates a full service Monday to Friday 8.30 am to 5.30pm with some scanning lists being extended into the evenings. This comprises of lists with booked outpatients, urgent suspected cancer patients, inpatients and clinical emergencies. At all other times a general X-ray service is offered alongside an emergency on call service for CT and ultrasound scanning. The emergency on call service is provided on a consultant to consultant basis for all cases where scanning is required to diagnose an emergency or life threatening condition.” Source location 2014-0302-Response-by-University-Health-Board
Open published response
17 Jan 2014 Selina Isabella Broadhurst · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of head CT guidance to support imaging for frail elderly patients without obvious neurological signs View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Selina Isabella Broadhurst · 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
Selina Isabella Broadhurst fell at the E.P.H. where she lived and suffered a head injury. She was not given a CT scan until a second hospital admission several hours later, when a major brain bleed was identified. The concern was that reliance on NICE guidelines may have contributed to missed or delayed diagnoses of severe brain injuries, particularly in very frail elderly patients.
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× 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 head CT guidance to support imaging for frail elderly patients without obvious neurological signs
Wider context from the report “The Emergency Department doctors indicated that they could not get a CT of the head because “the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs” .
I have noted in this inquest and indeed in a number of inquests previously that the doctors are following these guidelines and in fact many severe brain injury cases are being missed or there is a delay in diagnosis . Is it not now time that this guideline was re-examined and the advice amended, especially when dealing with the very frail elderly patient ?
” Source location Selina Isabella Broadhurst · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.