Unreliable review of diagnostic imaging before consequential care decisions
First to latest report 23 Sep 2013 — 25 Sep 2025
Reports that mention this concern
8
Times this concern has been raised
8
Stated actions linked to this concern
13
What this concern includes
Includes failures in the diagnostic-imaging review process where relevant images or reports are not reliably transferred, made available, tracked, reviewed or considered before a consequential clinical decision, including the anchor's failure to review CT C-spine images before surgery and comparable failures involving specialist advice or routine CT-report review.
What is not included
Excludes errors in interpreting imaging after the relevant images or reports were reviewed; those belong to the existing diagnostic-imaging interpretation concern.
Excludes failures to perform or complete an imaging investigation where the material deficiency is access or completion rather than review before a consequential decision.
Excludes generic clinical-record, communication or information-transfer deficiencies unless they directly prevent review or consideration of diagnostic imaging before a consequential care decision.
Excludes delays or failures in acting on an imaging result after it was reliably reviewed when the review process itself was adequate.
Excludes failures confined to a separately named imaging pathway where that pathway supplies the more specific supported parent boundary.
Trends
Reports over time
Reports mentioning this concern, 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.
Barking, Havering and Redbridge University Hospitals NHS Trust1
Care Quality Commission1
Department of Health and Social Care1
EMIS Group1
Mid and South Essex NHS Foundation Trust1
North Cumbria Integrated Care NHS Foundation Trust1
North West Anglia NHS Foundation Trust1
Recipient name withheld1
the Newcastle Upon Tyne Hospitals NHS Foundation Trust1
Worcestershire Acute Hospitals NHS Trust1
York and Scarborough Teaching Hospitals NHS Foundation Trust1
NHS trust7
Company1
Health and social care service regulator1
Ministerial department1
Type not available1
Reports and published responses 8 reports
See individual reports that have raised this concern, and the actions taken in response
North Yorkshire and York
Concerns raised1
Failure to check CT scan outcomes before patient discharge
This report raised 11 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.
Worcestershire
Concerns raised1
Failure to ensure that all locum doctors receive training to read both parts of CT scan reports
Linked response
Worcestershire Acute Hospitals NHS 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.3
Worcestershire Acute Hospitals NHS Trust
Deliver anonymised investigation learning through regular shop-floor teaching and board rounds to reach staff, including locum doctors.
Worcestershire Acute Hospitals NHS Trust
Email investigation learning to regular doctors, including locum doctors.
Worcestershire Acute Hospitals NHS Trust
Circulate a lesson-of-the-week reminder about reading both parts of CT scan reports.
Essex
Concerns raised1
Delays in MDT consideration of CT scan results and treatment plans
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mid and South Essex 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.2
Mid and South Essex NHS Foundation Trust
Operate a focused weekly kidney and upper-tract urological cancer MDT reviewing relevant recent scans with specialist multidisciplinary participation across hospital sites.
Mid and South Essex NHS Foundation Trust
Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Mid and South Essex NHS Foundation Trust
Weekly specialist MDT meetings and centralised tracking are considered sufficient to prevent delays in scan review and treatment planning.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Lack of a method for ensuring clinician review of routine CT scan reports
Linked response
North West Anglia 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.2
North West Anglia NHS Foundation Trust
Improve the electronic records system to include requested reports and enable tracking of report viewing.
North West Anglia NHS Foundation Trust
Produce monthly reports identifying unviewed routine radiology scans using the current radiology system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
North West Anglia NHS Foundation Trust
Clinicians who request routine scans and their departments remain primarily responsible for reviewing reports.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Failure to review CT C-spine images before burr-hole surgery
This report raised 5 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.
Cumbria
Concerns raised1
Failure of the result-filing function to prevent multiple-click filing of subsequent results without clinician review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
EMIS Group
North Cumbria Integrated Care 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.5
North Cumbria Integrated Care NHS Foundation Trust
Test a workable EMIS solution and continue collaborating with EMIS on system fixes, user communication and escalation of identified risks.
North Cumbria Integrated Care NHS Foundation Trust
Return the Cockermouth Hospital community ward to the ICE Order Comms system after assessing the affected functionality.
North Cumbria Integrated Care NHS Foundation Trust
Increase Neurology team vigilance when reviewing results and stop using “file no comment” in favour of “File and Comment” to require clinician review.
North Cumbria Integrated Care NHS Foundation Trust
Implement a separate Rad Alert system that emails referrers about significant radiology findings and escalates unacknowledged alerts to alternative clinicians.
North Cumbria Integrated Care NHS Foundation Trust
Notify Primary Care colleagues using EMIS about the risk and required precautions through the CCG Chief Clinical Information Officer.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
EMIS Group
Existing EMIS Web failsafes, combined with appropriate user diligence, are considered sufficient to prevent inadvertent filing of multiple results.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
EMIS Group
Clinicians are responsible for reviewing, filing and archiving results at a speed and diligence appropriate to their clinical nature and patient context.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North and West Cumbria
Concerns raised1
Failure to review CT scan images before providing specialist advice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
the Newcastle Upon Tyne Hospitals 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.1
the Newcastle Upon Tyne Hospitals NHS Foundation Trust
Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.
Milton Keynes
Concerns raised1
Lack of a robust process for tracking review of radiology reports by emergency department consultants
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.