Recurring concern

Unreliable X-ray request and progression processes

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First reported 21 Aug 2014•Latest report 24 May 2022

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable X-ray request and progression processes’ and satisfy this evidence boundary: Both distinct reports directly concern X-ray requests that were rejected, not properly made or not progressed promptly. No direct cross-report support establishes CT or diagnostic imaging generally, so preserve the specific X-ray object.

Not included

Excludes delays in performing or reporting imaging after a request has been reliably accepted and progressed.
Excludes failures limited to interpreting or acting on imaging findings after the imaging process has operated reliably.
Excludes generic clinical training, communication or documentation deficiencies unless they directly impair diagnostic-imaging request or escalation processes.
Excludes condition-specific imaging pathways where a narrower named concern provides the more specific supported boundary.
Excludes manifestations outside the manually reviewed boundary: Both distinct reports directly concern X-ray requests that were rejected, not properly made or not progressed promptly. No direct cross-report support establishes CT or diagnostic imaging generally, so preserve the specific X-ray object.

Reports: 5
Individual concerns: 6
Date range: 2014–2022
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

East Kent Hospitals University NHS Foundation Trust1

Hampshire Hospitals NHS Foundation Trust1

Mersey Care NHS Foundation Trust1

NHS England1

NHS Greater Manchester Integrated Care Board1

Park and St Francis Surgery1

the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust1

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust1

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.

24 May2022
Norfolk
Concerns raised1
1. Lack of escalation arrangements for outstanding x-ray 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completed
AI-generated summary

Michael Nestor WYSOCKYJY · 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

Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.

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
Lack of escalation arrangements for outstanding x-ray requests
Wider context from the report
“2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x-ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place. This is something that can be missed in a busy department. ”
Source location
Michael Nestor WYSOCKYJY · 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
Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.

Verbatim wording from the response
“Response: The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, this should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted).”

Source location
Response from NHS Queen Elizabeth Hospital Kings's Lynn
Page 2 · response
Published 24 May 2022
Open published response
29 Oct2019
South Yorkshire (Western)
Concerns raised2
1. Lack of necessary training for senior staff making x-ray requests
2. Failure of systems to ensure timely resolution of x-ray and CT requests
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.
AI-generated summary

Mrs Elizabeth Glen Self · 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

Mrs Elizabeth Glen Self was admitted to hospital following a heart attack and later suffered a serious fall after becoming entangled in a line attached to her left leg. Injuries were not immediately recognised, and there were delays of more than thirteen hours in dealing with requested x-rays and a CT scan. The concerns included inadequate training in making x-ray requests, a possible breakdown in communications, and systems that allowed imaging requests to remain unresolved for hours.

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
Lack of necessary training for senior staff making x-ray requests
Wider context from the report
“a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications. c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution. ”
Source location
Mrs Elizabeth Glen Self · 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 systems to ensure timely resolution of x-ray and CT requests
Wider context from the report
“a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications. c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution. ”
Source location
Mrs Elizabeth Glen Self · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Jan2018
Central Hampshire
Concerns raised1
1. Failure to ensure timely making and progression of X-ray 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review the procedure for requesting X-rays and discuss it with surgery doctors and staff.
  Stated by Partners at Park & St Francis SurgeriesStated completed
2. Action
  Send X-ray forms electronically to the hospital instead of printing them.
  Stated by Partners at Park & St Francis SurgeriesStated planned
3. Action
  Change the default ICE request location on the affected emergency-department computer to the emergency department.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
1. Action
  Educate emergency-department clinicians on correctly recording X-ray request locations in ICE.
  Stated by Hampshire Hospitals NHS Foundation TrustStated completed
AI-generated summary

Joan Elizabeth Betteridge · 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

Joan Elizabeth Betteridge, aged 88, died during surgery for a displaced fractured neck of femur after a series of falls and delays in identifying the fracture. She developed bradycardia shortly after bone cement was inserted and was pronounced dead despite resuscitation attempts; the post-mortem identified bone cement implantation syndrome, with ischaemic heart disease as a contributory condition. The concerns included delays in requesting and progressing repeat X-rays and a radiology review system that did not identify the fracture promptly.

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 ensure timely making and progression of X-ray requests
Wider context from the report
“I heard evidence that ████████ intended to request a repeat X-ray on 1 June but nothing happened until the physiotherapist queried this with a different GP in the same surgery. This raises concerns either that the request was not made or if it was made then it was not progressed in a timely fashion. A further request was made on 7 June and took place on 9 June, two days later. ”
Source location
Joan Elizabeth Betteridge · Prevention of Future Deaths report
Page 4 · 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
Review the procedure for requesting X-rays and discuss it with surgery doctors and staff.

Verbatim wording from the response
“████████ has undertaken a review of the procedure for requesting an X-ray and has discussed this with the doctors and staff at the surgery. Printed X-ray forms could cause a possible delay if they were to be collected from the surgery or have the potential to be mislaid if left at the patient’s home or residential faculty. Now that we have recently been given access to electronic X-ray forms it has been decided that doctors are to send X-ray forms electronically to the hospital rather than printing the forms. We have reminded all doctors that instructions to residential care staff and nurses should continue to be recorded clearly in the patient’s notes, as well as communicated explicitly, in order to avoid confusion regarding the management plan at a later stage.”

Source location
2018-0026-Response-by-St-Francis-Surgery
Page 1 · response
Published 20 March 2018
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
Send X-ray forms electronically to the hospital instead of printing them.

Verbatim wording from the response
“████████ has undertaken a review of the procedure for requesting an X-ray and has discussed this with the doctors and staff at the surgery. Printed X-ray forms could cause a possible delay if they were to be collected from the surgery or have the potential to be mislaid if left at the patient’s home or residential faculty. Now that we have recently been given access to electronic X-ray forms it has been decided that doctors are to send X-ray forms electronically to the hospital rather than printing the forms. We have reminded all doctors that instructions to residential care staff and nurses should continue to be recorded clearly in the patient’s notes, as well as communicated explicitly, in order to avoid confusion regarding the management plan at a later stage.”

Source location
2018-0026-Response-by-St-Francis-Surgery
Page 1 · response
Published 20 March 2018
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
Change the default ICE request location on the affected emergency-department computer to the emergency department.

Verbatim wording from the response
“The default location on that computer has since been changed to the emergency department. I am pleased to confirm that the other computers in the emergency department that are used for accessing ICE were already set to the correct default location.”

Source location
2018-0026-Response-by-Hampshire-NHS-Trust
Page 2 · response
Published 20 March 2018
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
Educate emergency-department clinicians on correctly recording X-ray request locations in ICE.

Verbatim wording from the response
“████████ Clinical Lead for Emergency Medicine, has also confirmed that the clinicians working in the emergency department have been educated on the importance of correctly recording the location of the requests, since this directly affects the timeframes for radiological review and reporting of images.”

Source location
2018-0026-Response-by-Hampshire-NHS-Trust
Page 2 · response
Published 20 March 2018
Open published response
28 Sep2015
Manchester West
Concerns raised1
1. Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements
This report raised 7 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.
AI-generated summary

Harry Pryal · 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

Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

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 Lakeside Unit clinicians to understand x-ray request and urgency requirements
Wider context from the report
“v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI. The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed. ”
Source location
Harry Pryal · Prevention of Future Deaths report
Page 4 · concerns
Open source report
21 Aug2014
Central and South East Kent
Concerns raised1
1. Failure to request a chest X-ray before aspiration
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 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.
AI-generated summary

Herbert Chandler · 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

Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

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 request a chest X-ray before aspiration
Wider context from the report
“A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”
Source location
Herbert Chandler · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of escalation arrangements for outstanding x-ray requests

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

Concerns raised2

Lack of necessary training for senior staff making x-ray requests

Failure of systems to ensure timely resolution of x-ray and CT requests

Concerns raised1

Failure to ensure timely making and progression of X-ray requests

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

Concerns raised1

Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements

Concerns raised1

Failure to request a chest X-ray before aspiration

Actions described in response 1

Actions described in response 4