Recurring concern

Inadequate safety guidance for CT scanning and reporting

First to latest report 4 Dec 2013 — 22 Dec 2025

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
21

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.

What is 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 and published responses 11 reports

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

  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

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