Recurring concern

Failure to provide timely access to clinically indicated CT scanning

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First reported 15 Oct 2013•Latest report 17 Feb 2025

Definition

What this concern includes

Includes failures of the CT-scanning access and provision process that delay, prevent or leave unresolved clinically indicated CT imaging, including direct referral access, service availability, out-of-hours or weekend provision, capacity, scheduling, authorisation and completion across clinical settings.

Not included

  • Excludes failures limited to interpretation, review or clinical action after CT images have been made available, unless access or completion is also deficient.
  • Excludes generic diagnostic-imaging, staffing, equipment or commissioning deficiencies that are not specifically tied to access to or provision of CT scanning.
  • Excludes other imaging modalities, including MRI, ultrasound and plain radiography, unless the assertion specifically concerns CT scanning.
  • Excludes failures limited to the content of a named CT request pathway where CT access or completion is not itself the unsafe condition.
Reports
26

Distinct published reports

Individual concerns
29

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
25

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 Care4
National Institute for Health and Care Excellence3
University Hospitals Sussex NHS Foundation Trust3
Care Quality Commission2
Manchester University NHS Foundation Trust2
NHS England2
Royal London Hospital2
Sandwell and West Birmingham Hospitals NHS Trust2
Stockport NHS Foundation Trust2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barts Health NHS Trust1
County Durham and Darlington NHS Foundation Trust1
Greater Manchester1
Homerton University Hospital1

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. Inner North London

    AI-generated summary

    Carl Edmond EASTMAN · 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

    Carl Eastman was admitted to hospital after a fall at home and later suffered an unwitnessed fall on 28 July 2024 while in hospital. He sustained an irreversible brain bleed and died in hospital that evening as a direct result of the injury. Concerns included delays in CT scans after falls, widespread communication and record-keeping issues, failure to follow post-fall procedures, and possible wider skills or knowledge deficits among staff.

    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

    Delays in CT scans where traumatic injury is suspected

    Wider context from the report

    “1. The consultant geriatrician’s evidence was that CT scan was requested to take place ‘as soon as possible’ following the first unwitnessed fall on 25 July 2024; however, they accepted that this was not conducted in a timely manner. Further, following the second unwitnessed fall on 28 July 2024, there was a further delay in a CT scan taking place. I was told that this scan should have been conducted within 1-2 hours of the request being made, yet it took place over three hours after the patient was reviewed by the doctor and the request for the scan was made. In Mr Eastman’s case, the delays in receiving the scans transpired to be immaterial in the particular circumstances. However, I am concerned that if delays in such scans, where traumatic injury is suspected, are repeated in the future, there is a risk that deaths could occur. ”

    Source location

    Carl Edmond EASTMAN · 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

    Review NICE guidance for emergency-department patients after falls to identify improvements to inpatient-fall imaging timeliness and reporting.

    Verbatim wording from the response

    “The Trust acknowledges that the scan being performed approximately 12 hours after being ordered on 25 July 2024, was not timely. In response, a review of the National Institute for Health and Care Excellence (NICE) treatment guidelines for patients presenting to the Emergency Department (ED) following a fall will be undertaken. This review will ascertain necessary improvements to the timeliness of image reporting for inpatient falls to support the earlier identification of any suspected injuries for treatment, and ongoing management to prevent any further deterioration to patients.”

    Source location

    Response from Royal Free London NHS Foundation Trust
    Page 2 · response
    Published 20 February 2025

    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

    Require overnight reporting of inpatient falls to the bed and site management team, with escalation when medical review is not completed within one hour.

    Verbatim wording from the response

    “In addition to these immediate measures, and to ensure all inpatient falls are reviewed and escalated in a timely manner, wards are required to report all inpatient falls through the hospitals bed and site management team between the hours of 19:30 and 07:30. The bed and site management team will have knowledge and oversight of all inpatient falls, and patients who are not reviewed by a doctor within 1 hour will be escalated through this team.”

    Source location

    Response from Royal Free London NHS Foundation Trust
    Page 3 · response
    Published 20 February 2025

    Open published response

  2. Manchester South

    AI-generated summary

    Celia Sanderson · 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

    Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

    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

    Delays in carrying out and reporting CT scans due to insufficient suitably qualified radiology staff

    Wider context from the report

    “3. Evidence given to the inquest indicated that the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed to ensure a timely transfer to a trauma unit. The inquest heard that timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient. The inquest was told that once CT scans were requested there were often delays due to a shortage of suitably qualified staff to carry them out and then to report on them. As an example of this the inquest was told that overnight 1 radiology registrar was responsible for reporting on CT scans for 3 hospitals (Wythenshawe, the MRI and RMCH) In Mrs Sanderson’s case this meant that the ED clinician had to wait for it to be carried out and then assess the CT scan without the report; ”

    Source location

    Celia Sanderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.

    Verbatim wording from the response

    “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 24 February 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

    Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.

    Verbatim wording from the response

    “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 24 February 2023

    Open published response

  3. East London

    AI-generated summary

    Ghulam Mohammad · 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

    Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

    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

    Delays in urgently requested CT head imaging

    Wider context from the report

    “2. Following that fall, an urgently requested CT head was delayed for four days. ”

    Source location

    Ghulam Mohammad · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Sunderland

    AI-generated summary

    Mr Alan Hodgson · 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 Alan Hodgson died at Sunderland Royal Hospital on 14 January 2021. The report describes failures to recognise the severity of his condition, delays in acting on and reporting imaging, failures to follow the vascular pathway, inadequate communication and continuity of care, and an insufficient review of the circumstances leading to his death.

    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

    Delays in CTA being performed

    Wider context from the report

    “(4) Poor communication between medical and radiology doctors resulting in: a) delays in CTA being performed; b) inadequate imaging being performed; and c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors. ”

    Source location

    Mr Alan Hodgson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. East London

    AI-generated summary

    Mr Paul Sartori · 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

    Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.

    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 access to CT scanning for suspected aortic dissection

    Wider context from the report

    “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection. The expert confirmed that misdiagnosis of aortic dissection is a very common problem. During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that: Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis: i. Lack of awareness and education ii. Access to CT scanning iii. Transfers to specialist centres The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain. Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to: i. Reliably diagnose or exclude aortic dissection ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon. The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection. ”

    Source location

    Mr Paul Sartori · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Alison Jean Shirley Jeanes · 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

    Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.

    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

    Lack of a system to fast track CT scans for patients on warfarin with suspected head injury

    Wider context from the report

    “2. Mrs Jeanes was brought into hospital by ambulance at the direction of a GP who recognised that she had a suspected head injury and was on warfarin. The GP recognised that the NICE guidance suggests there is an 8 hour window for patients on warfarin with a suspected head injury. Her fall had been at 23.58 on 16th March. The inquest heard that she was triaged but her CT scan was not expedited and was not reported on until 11.45 almost 12 hours after the fall. There was no evidence of a system that would fast track such cases for a CT scan. ”

    Source location

    Alison Jean Shirley Jeanes · 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

    Use the updated Emergency Department adult head injury pathway to guide assessment, CT scanning, neurosurgical referral and clinical documentation.

    Verbatim wording from the response

    “Emergency Department Head Injury Pathway I enclose the recently updated (in August 2020) local head injury pathway in place at Wythenshawe Hospital’s Emergency Department, for use by clinical staff when assessing adult patients for a head injury and for documenting the assessment in the patient’s clinical notes. This local pathway is in line with NICE guidance and serves to guide clinicians as to the steps to be undertaken to ensure a comprehensive assessment of patients presenting with a head injury. The local pathway specifically covers the indications for a CT scan and/or to contact the Neurosurgical specialists for advice and provides the template for documenting the outcome of CT scan/Neurosurgical advice in the clinical notes.”

    Source location

    2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 1 December 2020

    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

    Embed the Clinical Decision Support Tool in the Emergency Department Electronic Patient Record to guide adult head injury management and CT requirements.

    Verbatim wording from the response

    “I also enclose the “Clinical Decision Support Tool”, which contains a user friendly flow chart for use when assessing and treating adult patients presenting with head injuries, which covers the requirements around CT head scans being undertaken according to the patient’s risk category, as well as the circumstances in which advice should be sought from Salford Royal Hospital’s Neurosurgery team based on abnormality on the imaging. This tool is embedded within the Electronic Patient Record system used by clinicians in the Emergency Department as decision support software.”

    Source location

    2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 1 December 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

    The CT scan reporting delay was one hour beyond target but did not appear to have significantly contributed to the adverse outcome.

    Verbatim wording from the response

    “After the request was submitted by the ward at 08.32 hours, Mrs Jeanes attended Radiology and the scan was performed at 09.16 hours, i.e. within 44 minutes. This is within the required Key Performance Indicator (KPI)/target for imaging of this nature, which requires that for patients in the Emergency Department with a head injury, the required turnaround time from the scan being requested to being performed should be within an hour. The time from the scan being undertaken to a verified CT scan report being provided was two hours, with the report being verified at 11.16 hours, which the Radiology team accepts is one hour outside of the required KPI/target, according to which it is expected that CT scans of this nature requested by the Emergency Department are to be reported within an hour of the examination.”

    Source location

    2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 1 December 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

    The local head injury pathway and electronic decision-support tool provide existing guidance for timely CT scanning and neurosurgical referral.

    Verbatim wording from the response

    “Emergency Department Head Injury Pathway I enclose the recently updated (in August 2020) local head injury pathway in place at Wythenshawe Hospital’s Emergency Department, for use by clinical staff when assessing adult patients for a head injury and for documenting the assessment in the patient’s clinical notes. This local pathway is in line with NICE guidance and serves to guide clinicians as to the steps to be undertaken to ensure a comprehensive assessment of patients presenting with a head injury. The local pathway specifically covers the indications for a CT scan and/or to contact the Neurosurgical specialists for advice and provides the template for documenting the outcome of CT scan/Neurosurgical advice in the clinical notes.”

    Source location

    2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
    Page 6 · response
    Published 1 December 2020

    Open published response

  7. Swansea and Neath Port Talbot

    AI-generated summary

    Pamela Moran · 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

    Pamela Moran died at Morriston Hospital on 17 March 2017 after falling at Tonna Hospital and suffering fractures and a head injury. She developed an acute on chronic intracranial bleed, and the report identified three missed opportunities for a CT head scan, along with inadequate documentation and a system that relied on junior doctors to hand over requests for scans.

    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

    Lack of an overnight consultant authorisation pathway for next-day CT scans

    Wider context from the report

    “During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr ████████ conclusion noted at paragraph 6.5.6 that: “Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned. The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.” 1. There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival. 2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017. 3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift. ”

    Source location

    Pamela Moran · 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

    Failure to perform indicated CT head scans

    Wider context from the report

    “During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr ████████ conclusion noted at paragraph 6.5.6 that: “Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned. The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.” 1. There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival. 2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017. 3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift. ”

    Source location

    Pamela Moran · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Richard Lester Ridout · 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

    Richard Lester Ridout was involved in a single-vehicle road traffic collision on 20 January 2019 and was later readmitted with respiratory failure, where cervical fractures and pulmonary contusions were discovered. The inquest concluded that he died from Influenza A and streptococcal pneumonia causing sepsis and multiple organ failure. Concerns were raised that the assessment and escalation of treatment after the collision did not include a trauma call, trauma CT scan, or cervical spine imaging despite the reported collision circumstances, injuries, neck pain and medication use.

    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 carry out trauma series CT scans after high-energy injury

    Wider context from the report

    “(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out. (2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC. ”

    Source location

    Richard Lester Ridout · 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

    Develop a fractured-scapula management protocol advising cervical-spine and chest X-rays and a lower threshold for clinically indicated CT scanning.

    Verbatim wording from the response

    “While there was no clear clinical indication for a full trauma CT scan on this occasion, we are currently developing a protocol for the management of patients who have sustained a fractured scapula. The protocol will advise that these patients should now have x-rays of their cervical spine and chest, with a lower threshold to perform a CT scan if clinically indicated. The work on protocols is taking place across the two hospital sites and will be complete within 3 months.”

    Source location

    2019-0331-Response-by-Western-Sussex-Hospitals
    Page 1 · response
    Published 8 November 2019

    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

    There was no clear clinical indication for a full trauma CT scan in this case.

    Verbatim wording from the response

    “While there was no clear clinical indication for a full trauma CT scan on this occasion, we are currently developing a protocol for the management of patients who have sustained a fractured scapula. The protocol will advise that these patients should now have x-rays of their cervical spine and chest, with a lower threshold to perform a CT scan if clinically indicated. The work on protocols is taking place across the two hospital sites and will be complete within 3 months.”

    Source location

    2019-0331-Response-by-Western-Sussex-Hospitals
    Page 1 · response
    Published 8 November 2019

    Open published response

  9. Manchester South

    AI-generated summary

    Colin Bailey · 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

    Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.

    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 undertake CT brain/head scans after falls with head impact in patients taking anticoagulant medication

    Wider context from the report

    “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance. ”

    Source location

    Colin Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · 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

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    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 obtain an ordered CT scan

    Wider context from the report

    “(4) On the morning of the 7th at around 10.30 am. the attending Doctor wanted Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to have a CT scan. None of this was achieved before her death two hours later. She should have at least received the intravenous fluids and the Cyclazine. Again it seems that at this stage there was a failure to realise that she had not been given the Potassium she had been written up for in A&E. ”

    Source location

    Kalma RAM-HENMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026