First reported 4 Dec 2013•Latest report 22 Dec 2025
Definition
What this concern includes
Includes failures of guidance, protocols, pathways or related staff understanding specifically governing CT indications, contraindications, safe scanning arrangements, treatment-related CT decisions and reporting requirements.
Not included
Excludes general CT access, scanner capacity, scheduling or completion delays when no CT safety-guidance deficiency is identified.
Excludes failures limited to interpretation, follow-up or clinical action after a CT result when the CT guidance itself was adequate.
Excludes generic clinical training, documentation or governance deficiencies not specifically tied to safe CT scanning or reporting.
Excludes guidance for a separately bounded condition or pathway, such as aortic dissection, unless the assertion also supports the wider CT-scanning safety-guidance concern.
Reports
11
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
21
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 Care2
National Institute for Health and Care Excellence2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Betsi Cadwaladr University LHB1
Liverpool Heart and Chest Hospital1
Liverpool Heart and Chest Hospital NHS Foundation Trust1
Medica Reporting Limited1
North Cumbria Integrated Care NHS Foundation Trust1
Royal College of Surgeons of England1
Sandwell and West Birmingham Hospitals NHS Trust1
South Tyneside and Sunderland NHS Foundation Trust1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Association of Coloproctology of Great Britain and Ireland1
University Hospitals Birmingham NHS Foundation Trust1
Ysbyty Gwynedd1
NHS trust7
Executive non-departmental public body2
Healthcare site2
Ministerial department2
Health professional body1
Local health board1
Private limited company1
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.
Manchester South
Concerns raised2
Absence of a clear multidisciplinary protocol for CT scan requests
Failure to ensure clear and understood escalation routes for rejected CT scan requests
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Berkshire
Concerns raised1
Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
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 concerns
Each 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.3
Action
Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Stated by The Association of Coloproctology of Great Britain and IrelandStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Action
Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
Action
Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Stated by The Association of Coloproctology of Great Britain and IrelandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Stated by Royal College of Surgeons of EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinical guidance is primarily the responsibility of NICE and relevant Royal Colleges, while Trusts should implement appropriate local processes or guidance.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Further guidance on CT scanning after abdominal surgery with raised CRP is not required because existing guidance and evidence address anastomotic leaks.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.3
Action
Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
Action
Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
Action
Audit the acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2024.
Birmingham and Solihull
Concerns raised1
Failure to follow guidance on proceeding with CT scans without waiting for blood test results
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.4
Action
Display laminated posters explaining the emergency contrast CT guidance in acute surgical areas at all acute sites by 31 October 2023.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Publish and disseminate a Trust policy reflecting the June 2023 emergency contrast CT guidance to all clinical staff by 31 October 2023.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Update the online requesting system to reflect the emergency contrast CT guidance by 31 October 2023.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Discuss the emergency contrast CT guidance at relevant departmental governance meetings by 31 October 2023.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Manchester South
Concerns raised1
Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans
Responses linked to these concerns
Each 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.9
Action
Implement and circulate a formal policy requiring multiplanar views for reporting all relevant images.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Conduct annual audits of compliance with the multiplanar-view reporting policy and present results to divisional governance meetings.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Perform and report relevant images in-house, retaining images demonstrating use of multiplanar reconstruction instead of outsourcing them.
Stated by Liverpool Heart and Chest Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Train radiologists to use PACS multiplanar reformats when interpreting and reporting cross-sectional imaging.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Refresh and publish training materials highlighting PACS multiplanar reformat functionality for reporting radiologists.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Audit radiologist reporting, provide case-level feedback, and share relevant learning through regular reviews.
Stated by Medica Reporting LimitedStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Share learning from this case with reporting radiologists.
Stated by Medica Reporting LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Continue highlighting the importance of multiplanar reformat tools to reporting radiologists.
Stated by Medica Reporting LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Remind case reviewers to consider the importance of multiplanar reformats when reviewing reporting discrepancies.
Stated by Medica Reporting LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The reporter normally uses MPR tools, so the concern that their use was not assured is disputed.
Stated by Medica Reporting LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing MPR training, guidance, auditing, refresher training and shared learning address MPR use in CT reporting.
Stated by Medica Reporting LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
MPR tool use cannot be monitored or measured in a simple or meaningful way.
Stated by Medica Reporting LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Lack of national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Sunderland
Concerns raised1
Lack of documented protocols for treatment and 24/7 CT scanning and reporting
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Include the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.
Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.
Surrey
Concerns raised1
Lack of accessible guidance on the process for arranging CT scans
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 concerns
Each 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
Action
Provide revised out-of-hours CT-requesting guidance in full and abbreviated forms on the intranet and through junior-doctor induction.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2016.
North Wales (East and Central)
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 concerns
Each 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
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 LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of head CT guidance to support imaging for frail elderly patients without obvious neurological signs
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of guidance, protocols, pathways or related staff understanding specifically governing CT indications, contraindications, safe scanning arrangements, treatment-related CT decisions and reporting requirements.
