Recurring concern
Unreliable CT scan request and escalation processes
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Request correctionFirst reported 2 Jul 2014•Latest report 26 Feb 2026
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.
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.
- Reports
- 7
- Individual concerns
- 9
- Date range
- 2014–2026
- Stated actions
- 6
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response 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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Action
Implement a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.
Stated by Barts Health NHS Trust -
Action
Share case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.
Stated by Barts Health NHS Trust
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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Position
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response 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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Action
Share learning about considering CTPA instead of VQ scans for suspected pulmonary embolism with Radiology through governance processes.
Stated by Bolton NHS Foundation Trust
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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Position
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.
Stated by Bolton NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response 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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Action
Reinforce urgent deterioration escalation through Resident Doctor communications, safety alerts, telephone or face-to-face consultant contact, and appropriate diagnostic-test ordering.
Stated by HCA International Limited (trading as HCA Healthcare UK -
Action
Deliver Resident Doctor workshops covering escalation protocols, inquest learning, responsibilities, and responding to deteriorating patients.
Stated by HCA International Limited (trading as HCA Healthcare UK
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response 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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Action
Improve the time from Emergency Department CT request to reported result through a quality improvement project.
Stated by Royal Berkshire NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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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Position
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.
Stated by Betsi Cadwaladr University LHB
Data last updated 7 September 2026