Recurring concern

Failure to ensure clinician competence for ultrasound examinations

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First reported 21 Apr 2017•Latest report 17 May 2024

Definition

What this concern includes

Includes failures of training, competence assessment, authorisation, supervision or ongoing assurance specifically intended to ensure clinicians can safely perform ultrasound examinations, including FAST and comparable bedside or departmental ultrasound.

Not included

  • Excludes general clinical training, supervision or staffing deficiencies where ultrasound competence is not the identified unsafe condition.
  • Excludes failures in ultrasound availability, image interpretation, reporting or referral where clinician competence to perform the examination is not deficient.
  • Excludes equipment malfunction, maintenance or procurement failures unrelated to the examiner's competence or supervision.
  • Excludes non-ultrasound diagnostic procedures unless the assertion explicitly supports the same ultrasound-competence process.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2017–2024

First to latest report issue date

Stated actions
0

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.

Cardiff & Vale University LHB1
East Lancashire Hospitals NHS 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.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Antony Waring · 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

    Antony Waring died on 24 June 2020 after a suprapubic catheter insertion perforated two loops of small bowel, leading to peritonitis, intensive care admission and subsequent death. The concerns included delays in introducing a standard operating procedure, the proposed use of CT scanning rather than ultrasound, inadequate ultrasound training, chance-based allocation of high-risk patients, and inappropriate research about complication risks.

    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 ultrasound teaching for consultants unable to use ultrasound

    Wider context from the report

    “(3) in the four years since Antony Waring's death, the Trust has not provided a single ultrasound teaching session provided by the Trust to any consultant who is not capable of using ultrasound. ”

    Source location

    Antony Waring · Prevention of Future Deaths report
    Page 3 · 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

    It is not practically feasible to train Urology Consultants to the expertise required for rare, complex cases; Consultant Radiologists therefore provide ultrasound.

    Verbatim wording from the response

    “I can confirm that Suprapubic Catheter placement is only performed by clinicians who are trained and confident to perform that procedure.”

    Source location

    Response ELHT
    Page 3 · response
    Published 1 August 2024

    Open published response

  2. South Wales Central

    AI-generated summary

    David Thomas Evans · 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 Thomas Evans presented with severe abdominal pain and an ultrasound scan revealed an aortic diameter of 40mm, but no further investigation was conducted and he was discharged. He was later admitted with a ruptured aortic aneurysm, underwent emergency surgery, and died later that day from complications following a ruptured thoraco-abdominal aneurysm. Concerns included inadequate training and supervision for the FAST ultrasound examination, the routine non-retention of scan records, and insufficient escalation of care when a symptomatic patient has an identified abdominal aortic aneurysm.

    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 conduct FAST ultrasound examinations under supervision when required

    Wider context from the report

    “(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision. ”

    Source location

    David Thomas Evans · 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

    Failure to ensure necessary training for FAST ultrasound examination

    Wider context from the report

    “(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision. ”

    Source location

    David Thomas Evans · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026