Recurring concern

Inadequate safety guidance for CT scanning and reporting

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First reported 4 Dec 2013•Latest report 22 Dec 2025

Definition

What this concern includes

Includes failures of guidance, protocols, pathways or related staff understanding specifically governing CT indications, contraindications, safe scanning arrangements, treatment-related CT decisions and reporting requirements.

Not included

  • Excludes general CT access, scanner capacity, scheduling or completion delays when no CT safety-guidance deficiency is identified.
  • Excludes failures limited to interpretation, follow-up or clinical action after a CT result when the CT guidance itself was adequate.
  • Excludes generic clinical training, documentation or governance deficiencies not specifically tied to safe CT scanning or reporting.
  • Excludes guidance for a separately bounded condition or pathway, such as aortic dissection, unless the assertion also supports the wider CT-scanning safety-guidance concern.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
21

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 Care2
National Institute for Health and Care Excellence2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Betsi Cadwaladr University LHB1
Liverpool Heart and Chest Hospital1
Liverpool Heart and Chest Hospital NHS Foundation Trust1
Medica Reporting Limited1
North Cumbria Integrated Care NHS Foundation Trust1
Royal College of Surgeons of England1
Sandwell and West Birmingham Hospitals NHS Trust1
South Tyneside and Sunderland NHS Foundation Trust1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Association of Coloproctology of Great Britain and Ireland1
University Hospitals Birmingham NHS Foundation Trust1
Ysbyty Gwynedd1

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. North and West Cumbria

    AI-generated summary

    Keith Thomas Graham · 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

    Keith Thomas Graham was involved in a road traffic collision after colliding with a bullock while travelling by motorcycle and later died from multiple injuries on 28 May 2012. Concerns included the timing of summoning on-call clinicians, the use of CT scanning for seriously injured trauma patients, and the time between presentation and theatre, as well as a misplaced chest drain that damaged the liver.

    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 account for contraindications to CT scanning in seriously injured trauma patients

    Wider context from the report

    “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre. ”

    Source location

    Keith Thomas Graham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026