Unreliable clinical decisions about when CT scanning is needed
First to latest report 6 Aug 2018 — 22 Dec 2025
Reports that mention this concern
7
Times this concern has been raised
8
Stated actions linked to this concern
12
What this concern includes
Includes failures in clinical assessment and decision-making about whether CT scanning is indicated, including failure to reconsider CT after changing symptoms or findings, failure to obtain CT when required before discharge or consequential treatment, and failure of the CT-request decision process to provide an appropriate decision for an urgent diagnostic need.
What is not included
Excludes CT scanner outages, service capacity, scheduling and access failures where the clinical-indication decision itself is not deficient.
Excludes technical performance, image acquisition, reporting and interpretation failures after the decision to perform CT has been made.
Excludes deficiencies in general diagnostic imaging or non-CT investigations unless the assertion specifically concerns deciding whether CT scanning is needed.
Excludes generic clinical-record, communication or staffing deficiencies unless they directly cause an unreliable decision about CT indication.
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.
Department of Health and Social Care2
General Medical Council1
Royal College of Emergency Medicine1
Royal College of Surgeons of England1
Royal Free London NHS Foundation Trust1
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
The Society and College of Radiographers1
University Hospitals Birmingham NHS Foundation Trust1
NHS trust5
Health professional body2
Ministerial department2
Health and care professional regulator1
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Failure to ensure ward-level doctors can obtain urgent CT scan decisions when needed for diagnosis
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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.
Linked responses
Department of Health and Social Care
NHS England
Royal College of Surgeons of England
The Association of Coloproctology of Great Britain and Ireland
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
The Association of Coloproctology of Great Britain and Ireland
Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Royal College of Surgeons of England
Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Department of Health and Social Care
Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
The Association of Coloproctology of Great Britain and Ireland
Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Royal College of Surgeons of England
ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Clinical guidance is primarily the responsibility of NICE and relevant Royal Colleges, while Trusts should implement appropriate local processes or guidance.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Further guidance on CT scanning after abdominal surgery with raised CRP is not required because existing guidance and evidence address anastomotic leaks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to consider further CT scanning in light of drain issues
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised2
Failure to undertake an urgent CT scan for acute abdominal presentations
Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sandwell and West Birmingham Hospitals NHS 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.3
Sandwell and West Birmingham Hospitals NHS Trust
Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.
Sandwell and West Birmingham Hospitals NHS Trust
Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.
Sandwell and West Birmingham Hospitals NHS Trust
Audit the acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.
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.
Linked response
University Hospitals Birmingham 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.4
University Hospitals Birmingham NHS Foundation Trust
Display laminated posters explaining the emergency contrast CT guidance in acute surgical areas at all acute sites by 31 October 2023.
University Hospitals Birmingham NHS Foundation Trust
Publish and disseminate a Trust policy reflecting the June 2023 emergency contrast CT guidance to all clinical staff by 31 October 2023.
University Hospitals Birmingham NHS Foundation Trust
Update the online requesting system to reflect the emergency contrast CT guidance by 31 October 2023.
University Hospitals Birmingham NHS Foundation Trust
Discuss the emergency contrast CT guidance at relevant departmental governance meetings by 31 October 2023.
Surrey
Concerns raised1
Failure to undertake CT aorta imaging when aortic dissection is in the differential diagnosis
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Sunderland
Concerns raised1
Failure to obtain definitive diagnostic imaging before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
South Tyneside and Sunderland 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.2
South Tyneside and Sunderland NHS Foundation Trust
Include the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.
South Tyneside and Sunderland NHS Foundation Trust
Review and relaunch the injured elderly non-weight-bearing pathway across the Trust to raise clinicians’ awareness.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.