PFD report

Anne Lorraine Dyson · Prevention of Future Deaths report

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Issued 26 Aug 2025•Sunderland

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation
    Part of recurring concern: Failure to provide sufficient clinical information for diagnostic imaging interpretation
  2. Failure to ensure interpretation of the whole scan
    Part of recurring concern: Unreliable interpretation of diagnostic imaging
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 recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Share identified radiology learning with Trust radiologists, emphasising search extent, confirmation bias and comparison of relevant prior imaging.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
  2. Action

    Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 September 2025.
  3. Action

    Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation

Wider context from the report

“The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies greatly in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed. ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient clinical information for diagnostic imaging interpretation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure interpretation of the whole scan

Wider context from the report

“The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies greatly in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken. I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report. The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period. I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed. ”

Is this part of a recurring concern?

Yes — Unreliable interpretation of diagnostic imaging.

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

Share identified radiology learning with Trust radiologists, emphasising search extent, confirmation bias and comparison of relevant prior imaging.

Verbatim wording from the response

“As a Trust we have taken Anne Dyson’s death very seriously and as you heard at the inquest, we’ve taken steps to share the identified learning with relevant Radiologists within the Trust, highlighting the importance of Radiologists being satisfied with the extent of their search, being aware of the risk of confirmation bias and the importance of comparing prior relevant imaging, where appropriate.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

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

Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.

Verbatim wording from the response

“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

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

Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.

Verbatim wording from the response

“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

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

Develop a work instruction specifying the required clinical information for radiology examinations to proceed.

Verbatim wording from the response

“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

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

Issue Trust-wide communication updating current staff about the required clinical information for radiology requests.

Verbatim wording from the response

“The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Review existing radiology processes with the external reporting partner to consider strengthening internal and external processes.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 September 2025.
  2. 2

    Develop and approve a joint Trust–4Ways SOP defining radiology reporting responsibilities and requirements to document comparison of relevant prior imaging.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2025.

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 existing radiology processes with the external reporting partner to consider strengthening internal and external processes.

Verbatim wording from the response

“Following receipt of your Report to Prevent Future Deaths, the Trust has reviewed existing radiology processes, in liaison with 4Ways, who are an external radiology reporting partner of the Trust, to consider how we can strengthen current processes both internally and externally.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 2 September 2025

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

Develop and approve a joint Trust–4Ways SOP defining radiology reporting responsibilities and requirements to document comparison of relevant prior imaging.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) is also being developed between the Trust and 4Ways, which is currently going through internal review and sign off, to provide a more clearly defined clinical process for both Trust and 4Ways Radiologists, around the reporting of images to ensure there is a consistent approach amongst clinicians, with them being aware of their own responsibilities. As part of this SOP, clinicians are reminded of the need, where clinically relevant, to compare previous imaging, with the requirement to now include reference to either a new finding or mark that no other changes are noted, to make it clear that a comparison of relevant images has taken place.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 2 · response
Published 2 September 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026