Recurring concern

Failure to provide timely access to clinically indicated CT scanning

First to latest report 15 Oct 2013 — 17 Feb 2025

Reports that mention this concern
26
Times this concern has been raised
29
Stated actions linked to this concern
25

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.

What is 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 and published responses 26 reports

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

  1. North West Kent

    AI-generated summary

    Sandra Rhoda Marion Wood · 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

    Sandra Rhoda Marion Wood was sent to Tunbridge Wells Hospital on 17 April 2015 with a suspected bowel obstruction and was discharged with a diagnosis of UTI and constipation. She was found collapsed at home the following day, taken to Maidstone General Hospital, and died later that day; the post-mortem recorded bowel obstruction due to adhesions. The concerns included the lack of routine weekend CT scanning facilities, the procedure required for urgent scans, and the delay to scanning until after the weekend.

    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 weekend facilities for routine CT scans

    Wider context from the report

    “(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”

    Source location

    Sandra Rhoda Marion Wood · Prevention of Future Deaths report
    Page 1 · 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

    Lack of a specific application procedure for urgent CT scans

    Wider context from the report

    “(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”

    Source location

    Sandra Rhoda Marion Wood · Prevention of Future Deaths report
    Page 1 · 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

    The Trust disputes that weekend CT facilities are unavailable, stating emergency scans are provided without numerical restriction based on clinical need.

    Verbatim wording from the response

    “1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends.”

    Source location

    sandra-wood-Response
    Page 1 · response
    Published 12 February 2016

    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

    Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.

    Verbatim wording from the response

    “Without rehearsing my response, I am happy to assure you that there is sound reasoning behind our procedure. Patients fall under the care of consultants, but spend more time being actively treated by junior doctors. To ensure that patients are appropriately escalated for treatment of a worsening condition (in the full knowledge of the treating consultant) it is necessary to ensure that a consultant is aware when a patient is to be sent for a CT scan at all times. On weekdays when consultants are more readily available on-site within the Trust these referrals are less noticeable than out of hours or on weekends, but the procedure is always in place.”

    Source location

    sandra-wood-Response
    Page 2 · response
    Published 12 February 2016

    Open published response

  2. Inner North London

    AI-generated summary

    Shalini GANESH-RAM · 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

    Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

    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 performing and reporting planned CT scans

    Wider context from the report

    “2. When a plan was made at 1.30pm on Sunday the 9ᵗʰ for a CT scan, this was not performed and reported on until approximately 7.30pm that evening. ”

    Source location

    Shalini GANESH-RAM · 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 escalate concerning postoperative symptoms for CT imaging

    Wider context from the report

    “1. Whilst Ms Ganesh-Ram underwent many consultant reviews, a raised pulse, abdominal pain and lack of urine output on Saturday the 8ᵗʰ and the morning of Sunday the 9ᵗʰ did not prompt a CT scan. Reassurance was drawn from the fact that her pain was controlled, but I wonder whether this was false reassurance, given that it was controlled by Oramorph, dihydrocodeine and paracetamol. (Abdominal distension was not noted until the middle of the day on Sunday the 9ᵗʰ, probably because it was masked by a high body mass index.) ”

    Source location

    Shalini GANESH-RAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    John Michael Matthews · 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

    John Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

    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 sending patients for a head CT scan

    Wider context from the report

    “4. There was an unnecessary and to some extent unexplained delay in sending him for a CT scan of his head. ”

    Source location

    John Michael Matthews · 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

    Institute ED checklists preventing patients from leaving before requested investigations and treatments are completed.

    Verbatim wording from the response

    “For the future, to avoid a reoccurrence of this incident, we have instituted a system of checklists whereby a patient cannot leave the ED without all the investigations and treatments being completed. The investigations requested are clearly shown on Advantis ED therefore the nurse caring for the patient and the shift co-ordinator will be aware of investigations requested.”

    Source location

    2015-0034-Response-by-Stockport-NHS-Trust
    Page 3 · response
    Published 29 January 2015

    Open published response

  4. Manchester South

    AI-generated summary

    Agnes Mary Hannan · 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

    Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

    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

    Unavailability of CT scanning for the Emergency Department out of normal hours

    Wider context from the report

    “8. I was told that there is no CT scanner facility available for the use of the ED out of normal hours. This meant that a scan was delayed/missed and led to a delay in diagnosis of her underlying condition. ”

    Source location

    Agnes Mary Hannan · Prevention of Future Deaths report
    Page 1 · 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

    A CT scanner was available to the Emergency Department around the clock, so its unavailability could not have delayed or prevented diagnosis.

    Verbatim wording from the response

    “8. I was told that there is no CT scanner facility available for the use of the ED out of normal hours. This meant that a scan was delayed / missed and led to a delay in diagnosis of her underlying condition.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 4 · response
    Published 27 October 2014

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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 the hospital CT scanning service

    Wider context from the report

    “(10) A complete failure of the CT scanning service at this Hospital. This led Mr. Palmer to be denied a CT scan which would certainly have diagnosed his condition. This failure arose because the CT scanning system at this Hospital is unfit for purpose. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Black Country

    AI-generated summary

    Lucy KILVERT · 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

    Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.

    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 performing a CT scan of the head after hospital presentation

    Wider context from the report

    “namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”

    Source location

    Lucy KILVERT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026