Recurring concern

Unreliable coordination of radiology services between healthcare teams

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First reported 24 Nov 2014•Latest report 20 Nov 2024

Definition

What this concern includes

Includes failures in dedicated coordination of radiology services between healthcare teams or organisations, including service-agreement governance, shared interpretation of responsibilities, imaging-prioritisation communication, referral liaison and coordination of radiology requests.

Not included

Excludes failures limited to radiology image interpretation, reporting or follow-up after the coordination process has operated adequately.
Excludes generic communication, governance or inter-Trust coordination failures without a material radiology-service connection.
Excludes radiology workforce, equipment or scanning-capacity deficiencies where coordination between radiology and referring teams is not the unsafe condition.
Excludes failures belonging to a separately named diagnostic pathway when that pathway provides the more specific supported boundary.

Reports: 7
Individual concerns: 7
Date range: 2014–2024
Stated actions: 15

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.

Tameside and Glossop Integrated Care NHS Foundation Trust2

Barts Health NHS Trust1

Care Quality Commission1

Department of Health and Social Care1

East Lancashire Hospitals NHS Trust1

Mersey Care NHS Foundation Trust1

NHS Greater Manchester Integrated Care Board1

North Cumbria Integrated Care NHS Foundation Trust1

Royal Bolton Hospital1

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation 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.

20 Nov2024
Manchester West
Concerns raised1
1. Failure to liaise with radiology when a preferred scan type requires discussion
This report raised 2 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
  Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.
  Stated by Bolton NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The established PE referral pathway and radiologist-led modality selection were considered sufficient; clinician-radiologist discussion is required only when departing from protocol or guidance.
  Stated by Bolton NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Charlotte Ann ROSCOE · 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

Charlotte Ann ROSCOE attended hospital with chest pains and was discharged after a VQ scan found no pulmonary embolism. She was found deceased at home the following day; post-mortem examination identified haemopericardium caused by rupture and dissection of the ascending aorta. Concerns included the missed opportunity to detect the aortic dissection by CT, reliance on outdated observations at discharge, and unclear processes for specifying and communicating scan requests with radiology.

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 liaise with radiology when a preferred scan type requires discussion
Wider context from the report
“2. Evidence was received from a doctor who referred the deceased for a scan, that she had thought she had requested a CTPA to be undertaken, but the form that was used was a request for an “acute pulmonary embolus investigation” which meant that the request would be vetted and an appropriate mode of scan arranged following consideration by a radiologist. It was stated by the doctor that it would not be normal to speak to radiology regarding a request for a scan. 3. In evidence from a radiologist it was stated that a medical clinician would be expected to speak to a radiologist if there was any preference for a type of scan to be undertaken so this could be discussed. It appeared to me that the use of the correct form, need to be specific, provide rationale for a specific type of scan request, and liaising with radiology as appropriate was not appreciated in this case. As above, given that there was no radiographer involved in the After Action Report or action raised, it is unclear if this matter has been considered, or any actions taken to prevent future confusion. ”
Source location
Charlotte Ann ROSCOE · 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
Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.

Verbatim wording from the response
“The AAR was approved through the Divisional Governance Board, which is the standard governance process. The potential area of learning regarding whether a CT Pulmonary Angiogram (CTPA) scan should be considered in place of a VQ scan for all patients suspected as having a PE, was shared with radiology via the Diagnostic and Support Services Division governance processes for their consideration. The AAR was then disclosed to HM Coroner as per the usual disclosure processes.”

Source location
Response from NHS Bolton
Page 3 · response
Published 26 November 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
The established PE referral pathway and radiologist-led modality selection were considered sufficient; clinician-radiologist discussion is required only when departing from protocol or guidance.

Verbatim wording from the response
“The request card/form used in the ED is for a referral for a scan to exclude PE. The radiologists are the experts who determine the modality based on the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R); the technical nature of the imaging and the clinical question posed. The form used clearly states that the scan is to exclude a PE and is not a specific form used to request a specific scan or modality. This form has been used in the trust for several years.”

Source location
Response from NHS Bolton
Page 3 · response
Published 26 November 2024
Open published response
25 Sep2023
Newcastle and North Tyneside
Concerns raised1
1. Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
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 3
1. Action
  Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated completed
2. Action
  Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated completed
3. Action
  Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
Respondent positions 3
1. Position
  Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.
  Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to act
1. Position
  Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.
  Stated by North Cumbria Integrated Care NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.
  Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concern
AI-generated summary

Brian David MORETON · 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

Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

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
Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
Wider context from the report
“- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”
Source location
Brian David MORETON · 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
Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.

Verbatim wording from the response
“In August 2022, the Trust ratified a protocol, which sets out a clear referral flow chart for the authorisation of CT imaging for adults. If a CT scan is indicated, the patient must be reviewed or discussed with a senior decision maker within the referring team, and the referrer must make a written referral on ICE (as is the process for all imaging), with reference to who the senior decision maker is within the referral. If the request falls within the Rapid Radiology Request Pathway (“RRRP”) criteria below, this can be discussed with a CT Radiographer without the requirement to discuss this with a Radiologist or the referrer:”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023
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
Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.

Verbatim wording from the response
“The Trust however recognises that there may be occasions where referrers and the Radiology Department need to discuss a referral. As aforementioned, such discussions were not documented or recorded at the time of Mr Moreton’s admission. The Radiology Department utilises RIS (radiology information system) which has the ability to document any relevant information, and each Radiologist has access to the system. Following Mr Moreton’s death, Radiology staff have been reminded of situations where it might be appropriate to record information on RIS, particularly discussions during the justification process, which could be reviewed by the Reporting Radiologist, if the imaging was justified by another Radiologist.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
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
Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

Verbatim wording from the response
“Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within various policies and SOPs, it would appear that this system has lost momentum within the Trust. SBAR is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to achieve this. Clinicians will be expected to utilise SBAR in any escalation of a clinical problem that requires attention, or to facilitate efficient handover, both internally and externally.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023
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
Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.

Verbatim wording from the response
“Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
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
Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.

Verbatim wording from the response
“Furthermore, there is no longer the expectation or requirement for referrers to discuss referrals for any imaging with a Radiologist. Whilst the duty line is still operational for referrers, Radiographers and Radiologists to discuss any requests being made, it is process for a robust ICE written referral to be made, and it is on that basis that the majority of imaging requests are justified or rejected, either by a Radiographer or Radiologist (depending on the above criteria), without the need for further discussion.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023
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
Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.

Verbatim wording from the response
“Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023
Open published response
2 Mar2021
Lancashire and Blackburn with Darwen
Concerns raised1
1. Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need
This report raised 16 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 2
1. Action
  Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.
  Stated by East Lancashire Hospitals NHS TrustStated completed
2. Action
  Review inpatient radiology priorities at vetting stage and align time-based priorities with NICE guidance where applicable.
  Stated by East Lancashire Hospitals NHS TrustStated in progress
AI-generated summary

Mr Frank Charles Medley · 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

Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

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
Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need
Wider context from the report
“(2) The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest. b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance; c. The case was inappropriately allocated to a structured judgement review; d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading; e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor"; iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust); iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest; v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event. f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan; g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services; h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG; i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation; j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day. k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need; l. There was insufficient senior clinical oversight of the conclusions drawn. ”
Source location
Mr Frank Charles Medley · 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
Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.

Verbatim wording from the response
“Clinico-radiological meetings were established in November 2020 and now occur twice weekly on Monday and Friday on AMU. It is intended that when possible, a third meeting will be provided on a Wednesday to provide better support through the working week. This development allows a forum in which difficult cases can be discussed and advice and guidance provided on the optimum imaging technique and/or interpretation of unusual report findings and has been a significant success; building improved relationships and communication between clinical teams on AMU and the radiology directorate. This meeting explicitly addresses the human factors highlighted in this case; ensuring that patient management is equitable regardless of the staff on duty and that clinical discussions can be held without personal attendance.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 4 · response
Published 8 March 2021
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
Review inpatient radiology priorities at vetting stage and align time-based priorities with NICE guidance where applicable.

Verbatim wording from the response
“We are currently also reviewing the In-patient priorities applied at vetting stage by Radiology. It is anticipated that these will be time-based allowing a better understanding of the priority applied at vetting; aligned to NICE guidance for urgent imaging where stated. This will allow pressures within the system to be escalated so that clinical decisions can be made on how best to proceed.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 5 · response
Published 8 March 2021
Open published response
20 Dec2019
Inner North London
Concerns raised1
1. Failure to ensure communication between interventional radiology and hepatology specialists
This report raised 5 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
  Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
  Stated by Barts Health NHS TrustStated completed
Respondent positions 1
1. Position
  Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Keith HILL · 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 Hill was admitted with biliary sepsis and underwent a liver biopsy, after which he developed bleeding requiring surgery and later suffered bowel haemorrhage. The report identified concerns about communication between specialists, inadequate medical records, and insufficient support and scrutiny around the prescription and dispensing of micafungin.

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 ensure communication between interventional radiology and hepatology specialists
Wider context from the report
“1. When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and a more accurate record of the decision making. ”
Source location
Keith HILL · 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
Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.

Verbatim wording from the response
“This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.”

Source location
2019-0446-Response-from-Barts-NHS-Trust-R
Page 1 · response
Published 6 January 2020
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
Further discussions with the referring team at the procedure stage would not have changed the procedure performed.

Verbatim wording from the response
“This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.”

Source location
2019-0446-Response-from-Barts-NHS-Trust-R
Page 1 · response
Published 6 January 2020
Open published response
28 Jun2016
Manchester South
Concerns raised1
1. Poor communication between radiology staff and clinicians and nurses
This report raised 6 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 2
1. Action
  Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
AI-generated summary

David Michael little · 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

David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

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
Poor communication between radiology staff and clinicians and nurses
Wider context from the report
“4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses. There was little or no good communication with the family which led to additional distress for them at a time of great sorrow. ”
Source location
David Michael little · Prevention of Future Deaths report
Page 1 · 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
Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

Verbatim wording from the response
“Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.”

Source location
2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016
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
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

Verbatim wording from the response
“In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.”

Source location
2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016
Open published response
28 Sep2015
Manchester West
Concerns raised1
1. Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
This report raised 7 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 2
1. Action
  Review and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progress
2. Action
  Complete a joint review of the Radiology Service Agreement to place patient safety at the centre of its specification.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Harry Pryal · 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

Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

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 of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
Wider context from the report
“ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1. The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place. The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh. During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement. ”
Source location
Harry Pryal · 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
Review and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.

Verbatim wording from the response
“A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway. This includes, and has started with the service level agreement for the provision of radiology services. The review process will incorporate the following steps:”

Source location
2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
Page 2 · response
Published 28 September 2015
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
Complete a joint review of the Radiology Service Agreement to place patient safety at the centre of its specification.

Verbatim wording from the response
“Shortly following the conclusion of Mr Pryal’s inquest, discussions were held regarding the interpretation of the Service Agreement for Radiology between the two organisations. Leading on these discussions for the Trust has been ████████ (Associate Director of Finance) and Andrew Beatty (Radiology Directorate Manager), with ████████ (Contract Manager for 5BP).”

Source location
2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Page 3 · response
Published 28 September 2015
Open published response
24 Nov2014
Manchester South
Concerns raised1
1. Failure to require radiology to urgently report findings to treating clinicians
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 4
1. Action
  Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
2. Action
  Operate the Results Governance Steering Group to implement and continuously improve results-governance processes, with monthly meetings.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
3. Action
  Review the Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
1. Action
  Review frameworks for tracking and following up all radiology reports and ensure they are robust.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
AI-generated summary

HAROLD PENNY · 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

HAROLD PENNY was admitted to hospital on 12 June 2014 and died on 20 June after investigations found a grossly distended bladder and a misplaced urinary catheter. The principal concern was that there was no system requiring radiology staff to rectify such problems where possible or urgently report them to treating clinicians.

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 require radiology to urgently report findings to treating clinicians
Wider context from the report
“There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible, nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage. ”
Source location
HAROLD PENNY · Prevention of Future Deaths report
Page 1 · 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
Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.

Verbatim wording from the response
“Work is being undertaken in this area at the Trust as part of the Sign up to Safety campaign which was launched by the Secretary of State for Health on 24 June 2014 with a mission to strengthen patient safety in the NHS. A draft ‘Radiology Requesting and Reporting Policy’ has been produced by the Trust and is currently going through our governance procedures.”

Source location
2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 1 · response
Published 24 November 2014
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
Operate the Results Governance Steering Group to implement and continuously improve results-governance processes, with monthly meetings.

Verbatim wording from the response
“A Results Governance Steering Group (RGSG) was also developed in October 2013 and is one of ten project teams that report to the Tameside Hospital Patient Safety Programme Board (PSPB) as part of the ‘Keeping patients safe and reducing harm’ programme. The RGSG met for the first time on 4 November 2014 and is concerned with ensuring that the Trust has clinical and operational processes to adequately support effective results governance. The scope of this group is to ensure that effective results governance processes are in place to timely recognition and escalation of abnormal clinical results. The 2014-2015 objectives of this group specifically include improving the standards of results governance from both a report and service delivery perspective. The group has completed an initial review of processes and is now meeting monthly to ensure implementation and continuous improvement.”

Source location
2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014
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
Review the Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.

Verbatim wording from the response
“Department examinations the same day. Where there are urgent findings (where medical evaluation is needed within 24 hours) the expectation will be that these are reported within four hours, the time frame depending on the nature of the imaging findings. Priority is given to inpatients, urgent requests and unexpected significant findings. The Trust’s objective is to document significant radiological findings and ensure they are communicated in a timely and unequivocal fashion. The Trust is reviewing its IT infrastructure to ensure this support is in place.”

Source location
2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 24 November 2014
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
Review frameworks for tracking and following up all radiology reports and ensure they are robust.

Verbatim wording from the response
“As set out above, the policy that we are in the process of ratifying, places a great deal of responsibility with the Radiologists within the Trust. However, it is important to note the responsibilities of the referring clinicians also. It is their responsibility to ensure that they have in place a robust system to enable tracking and follow up of all radiology reports. One of the focus areas of the RGSG is to review frameworks for tracking and follow up of all radiology reports and ensure these are robust. Once received, reports should be legibly signed, dated and filed in a permanent patient record with a clear indication of any action taken following receipt of the report. It is the responsibility of the referring clinician to ensure this takes place and individual systems in place will be subject to regular audit.”

Source location
2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 4 · response
Published 24 November 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to liaise with radiology when a preferred scan type requires discussion

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

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

Concerns raised1

Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need

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

Concerns raised1

Failure to ensure communication between interventional radiology and hepatology specialists

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

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

Concerns raised1

Poor communication between radiology staff and clinicians and nurses

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

Concerns raised1

Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement

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

Concerns raised1

Failure to require radiology to urgently report findings to treating clinicians

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.4

Actions described in response 1

Respondent positions 1

Actions described in response 3

Respondent positions 3

Actions described in response 2

Actions described in response 1

Respondent positions 1

Actions described in response 2

Actions described in response 2

Actions described in response 4