Recurring concern

Unreliable CTPA investigation and follow-up

First to latest report 20 May 2014 — 7 Mar 2022

Reports that mention this concern
3
Times this concern has been raised
6
Stated actions linked to this concern
2

What this concern includes

Includes failures of the CTPA process from requesting and communicating the procedure through completion, identification of missing procedures and timely follow-up or escalation.

What is not included
  • Excludes failures concerning other diagnostic tests or scan modalities unless they are directly part of the same CTPA process.
  • Excludes generic communication, documentation or staffing deficiencies that are not specifically tied to CTPA investigation or follow-up.
  • Excludes clinical decisions about whether CTPA is the appropriate modality where no failure in CTPA completion or follow-up is identified.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    ARTHUR FREDERICK HALL · 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

    Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

    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 undertake second-line investigation of suspected perforation

    Wider context from the report

    “3. Second line of enquiry (endoscopy or CTPA) was not undertaken. ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    Olive Darbyshire · 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

    Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.

    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 complete urgent CTPA requests promptly

    Wider context from the report

    “1. Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, I am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place and that this had not happened some three days after the request was made. ”

    Source location

    Olive Darbyshire · Prevention of Future Deaths report
    Page 2 · 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 of the clinical team to follow up missing CTPA procedures

    Wider context from the report

    “2. I am concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire's care making efforts to “chase up” the missing CTPA procedure. ”

    Source location

    Olive Darbyshire · Prevention of Future Deaths report
    Page 2 · 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

    Incorrect categorisation of urgent CTPA requests as outpatient requests

    Wider context from the report

    “3. I am concerned that the radiology department staff have incorrectly categorised Mrs Darbyshire in a way that meant that she spent a number of days in hospital awaiting an urgent CTPA procedure that in reality was not going to happen because once categorised as an outpatient she realistically would only expect to receive a CTPA in 2015 by way of a written notification. ”

    Source location

    Olive Darbyshire · Prevention of Future Deaths report
    Page 2 · 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 process urgent CTPA requests during holiday periods

    Wider context from the report

    “4. I am concerned that given this request was made on 23rd December 2014, subsequent events have been influenced by the fact that the request was made shortly before the Christmas period and that a lack of action taken by the clinical team to “chase up” the CTPA and the actions of the radiology department administration staff have been influenced by reduced staffing levels over the Christmas holiday period when the department would deal with inpatient requests only, and emergency requests pertaining to Accident & Emergency patients. ”

    Source location

    Olive Darbyshire · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.

    Verbatim wording from the response

    “There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weaknesses regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.”

    Source location

    Olive-Darbyshire-Response
    Page 2 · response
    Published 22 May 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.

    Verbatim wording from the response

    “This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.”

    Source location

    Olive-Darbyshire-Response
    Page 2 · response
    Published 22 May 2015

    Open published response

  3. Surrey

    AI-generated summary

    Rainer Wickens · 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

    Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.

    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 of communication between junior doctors and radiologists causing delay in CTPA

    Wider context from the report

    “Breakdown in communication between junior doctor and radiologist resulting in avoidable delay of CTPA ”

    Source location

    Rainer Wickens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026