Recurring concern

Unreliable access to timely MRI scanning

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First reported 2 Mar 2021•Latest report 24 Apr 2021

Definition

What this concern includes

Includes failures of the MRI scanning access and capacity process that delay or make unavailable urgent MRI scans, including insufficient scanner capacity, unavailable scanning slots, and failure to evaluate whether capacity changes improve urgent scan times.

Not included

Excludes CT, CTPA, VQ, ultrasound and other diagnostic modalities unless the report explicitly connects the deficiency to MRI access.
Excludes radiologist or radiographer workforce shortages where MRI access or MRI capacity is not the identified unsafe condition.
Excludes failures of image transfer, PACS availability or clinical interpretation after an MRI has been performed.
Excludes generic evaluation, governance or improvement failures that are not specifically tied to MRI capacity or timely access to MRI scanning.

Reports: 2
Individual concerns: 4
Date range: 2021–2021
Stated actions: 10

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.

Care Quality Commission1

East Lancashire Hospitals NHS Trust1

Greater Manchester Health and Social Care Partnership1

NHS England1

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.

24 Apr2021
Manchester South
Concerns raised1
1. Insufficient MRI scanner capacity and availability
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
  Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.
  Stated by NHS EnglandStated completed
2. Action
  Increase imaging equipment capacity in England to address diagnostic service demand.
  Stated by NHS EnglandStated in progress
3. Action
  Develop community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.
  Stated by NHS EnglandStated planned
1. Action
  Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
AI-generated summary

Alfred Jones · 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

Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.

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
Insufficient MRI scanner capacity and availability
Wider context from the report
“1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”
Source location
Alfred Jones · 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
Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.

Verbatim wording from the response
“From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

Source location
2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 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
Increase imaging equipment capacity in England to address diagnostic service demand.

Verbatim wording from the response
“From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

Source location
2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 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
Develop community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.

Verbatim wording from the response
“Funding within the 2021/22 spending review has been targeted to support diagnostics via the development of community diagnostic hubs which will in turn augment access for inpatient activity in acute hospital services through the movement of elective activity to community settings. It is anticipated that MRI, CT scanning, Ultrasound and X-ray services will be the core imaging offer for these new centres and will represent new additional imaging capacity.”

Source location
2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 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
Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.

Verbatim wording from the response
“Tameside and Glossop Integrated Care NHS FT At the time of Mr Jones’ referral, Tameside and Glossop Integrated Care NHS Foundation Trust (T&GIC FT) was sourcing additional scanner capacity by provision of a mobile MRI scanner. This was implemented on 20th September 2020, offering additional outpatient scanning capacity for 12 hours per day, 7 days per week. The mobile MRI van is still used currently to provide additional capacity. It is also worth noting that the Trust did not reduce or delay suspected cancer patient scans due to the pandemic, and therefore, the MRI scanner was being fully utilised.”

Source location
2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021
Open published response
2 Mar2021
Lancashire and Blackburn with Darwen
Concerns raised3
1. Failure to expedite emergency MRI scanning and document escalation attempts
2. Insufficient MRI scanner capacity for urgent scans
3. Failure to evaluate whether MRI capacity changes improve urgent scan times
This report raised 14 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 6
1. Action
  Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
  Stated by East Lancashire Hospitals NHS TrustStated completed
2. Action
  Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
  Stated by East Lancashire Hospitals NHS TrustStated in progress
3. Action
  Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.
  Stated by East Lancashire Hospitals NHS TrustStated completed
1. Action
  Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.
  Stated by East Lancashire Hospitals NHS TrustStated in progress
2. Action
  Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.
  Stated by East Lancashire Hospitals NHS TrustStated in progress
3. Action
  Roll out the radiology inpatient dashboard to wards and clinical services.
  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
Failure to expedite emergency MRI scanning and document escalation attempts
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 individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient MRI scanner capacity for urgent scans
Wider context from the report
“(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans. ”
Source location
Mr Frank Charles Medley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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 evaluate whether MRI capacity changes improve urgent scan times
Wider context from the report
“(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans. ”
Source location
Mr Frank Charles Medley · 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
Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.

Verbatim wording from the response
“Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.”

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
Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.

Verbatim wording from the response
“Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.”

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
Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.

Verbatim wording from the response
“The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 5 · 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
Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.

Verbatim wording from the response
“The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 5 · 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
Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.

Verbatim wording from the response
“In October 2020, ELHT commissioned two new Magnetic Resonance Imaging (MRI) systems on the Burnley General Teaching Hospital site. These scanners were replacement assets identified as part of the government initiative which aimed to replace all MRI systems over 10 years old. The initial intention was to replace the Philips MRI system at Burnley and the Trust owned asset at RBH. However, due to”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 3 · 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
Roll out the radiology inpatient dashboard to wards and clinical services.

Verbatim wording from the response
“The Radiology in patient dashboard has been developed using our business intelligence system and is currently used in key areas of the Trust. Roll out of the dashboard is progressing. The next steps are to demonstrate and share access to the dashboard at the Nursing & Midwifery Forum, Foundation Teaching and Clinical Leadership to accelerate roll out to the wards and clinical services.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 4 · response
Published 8 March 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient MRI scanner capacity and availability

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

Concerns raised3

Failure to expedite emergency MRI scanning and document escalation attempts

Insufficient MRI scanner capacity for urgent scans

Failure to evaluate whether MRI capacity changes improve urgent scan times

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.6

Actions described in response 4

Actions described in response 6