Recurring concern
Unreliable CT scan request and escalation processes
- Reports that mention this concern
- 7
- Times this concern has been raised
- 9
- Stated actions linked to this concern
- 6
What this concern includes
Includes failures in the dedicated CT scan request process, including request criteria and acceptance, multidisciplinary or radiology decision-making, escalation when requests are declined or disputed, out-of-hours requesting arrangements, communication between requesting clinicians and radiology, and records that make request decisions traceable.
What is not included
- Excludes failures limited to CT scan access, scanner capacity or delays after a request has been appropriately accepted unless the assertion also concerns the request and escalation process.
- Excludes failures in interpreting, reviewing or acting on CT results after the request process has operated reliably.
- Excludes deficiencies in general clinical guidance for deciding whether CT is indicated when no failure in the CT-request process or its escalation arrangements is identified.
- Excludes patient-identification, contrast-administration and traction-specific CT safety controls unless the assertion directly concerns CT request or escalation arrangements.
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.
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to make decisive urgent CT head scan referrals
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
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
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Barts Health NHS Trust
Implement a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.
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Barts Health NHS Trust
Share case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Department of Health and Social Care
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
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Concerns raised3
Absence of a clear multidisciplinary protocol for CT scan requests
Failure to maintain comprehensive records of decision-making on CT scan requests
Failure to ensure clear and understood escalation routes for rejected CT scan requests
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to liaise with radiology when a preferred scan type requires discussion
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Bolton 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
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Bolton NHS Foundation Trust
Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Bolton NHS Foundation Trust
The established PE referral pathway and radiologist-led modality selection were considered sufficient; clinician-radiologist discussion is required only when departing from protocol or guidance.
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Concerns raised1
Failure to ensure resident doctors understand their authority to commence CT scan ordering
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HCA International Limited (trading as HCA Healthcare UK
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
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HCA International Limited (trading as HCA Healthcare UK
Reinforce urgent deterioration escalation through Resident Doctor communications, safety alerts, telephone or face-to-face consultant contact, and appropriate diagnostic-test ordering.
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HCA International Limited (trading as HCA Healthcare UK
Deliver Resident Doctor workshops covering escalation protocols, inquest learning, responsibilities, and responding to deteriorating patients.
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Concerns raised1
Burdensome and time-consuming out-of-hours CT scan requesting system
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Berkshire 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
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Royal Berkshire NHS Foundation Trust
Improve the time from Emergency Department CT request to reported result through a quality improvement project.
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Concerns raised1
Failure of systems to ensure timely resolution of x-ray and CT requests
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inconsistent criteria for requesting CT scans outside standard hours and at weekends
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Betsi Cadwaladr University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Betsi Cadwaladr University LHB
Existing emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026