PFD report

Lydia Corah · Prevention of Future Deaths report

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Issued 11 May 2015•Nottinghamshire

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised1

  1. Failure to ensure that x-rays are performed for the patient for whom they are intended
    Part of recurring concern: Unreliable patient identification during healthcare contacts
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.4

  1. Action

    Consider introducing stronger technological barriers, including a patient photograph, to prevent incorrect patient selection in Notis.

    Stated by Nottingham University HospitalStated plannedThe respondent said that this action was planned when they made their response on 11 May 2015.
  2. Action

    Operate an established system for reporting and investigating recognised ionising-radiation incidents, including routine root-cause analysis of incorrect imaging referrals.

    Stated by Nottingham University HospitalStated completedThe respondent said that this action was complete when they made their response on 11 May 2015.
  3. Action

    Strengthen induction training for new doctors on avoiding multiple open patient pages in the Notis system.

    Stated by Nottingham University HospitalStated completedThe respondent said that this action was complete when they made their response on 11 May 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    No technological safeguard for incorrect patient selection was implemented because potential barriers were considered capable of creating other patient safety concerns.

    Stated by Nottingham University HospitalUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 that x-rays are performed for the patient for whom they are intended

Wider context from the report

“1. That there was an error, or series of errors, which led to Mrs Corah undergoing an x ray which had been indicated for a different patient, so causing her to experience delay in assessment and treatment and to receive an unnecessary dose of radiation. 2. That the same error, or series of errors, would have adversely affected the patient for whom the x ray request had been properly intended. ”

Is this part of a recurring concern?

Yes — Unreliable patient identification during healthcare contacts.

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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

Consider introducing stronger technological barriers, including a patient photograph, to prevent incorrect patient selection in Notis.

Verbatim wording from the response

“g. The only addition safeguard which has been proposed is the inclusion of a patient photo to the Notis page. This has not been progressed but will be considered in the near future by the NUH Clinical Risk Committee.”

Source location

2015-0181-Response
Page 2 · response
Published 11 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

Operate an established system for reporting and investigating recognised ionising-radiation incidents, including routine root-cause analysis of incorrect imaging referrals.

Verbatim wording from the response

“e. A Root Cause Analysis is routinely employed in all cases of incorrect referrals for medical imaging. The RCA will generate an action plan which is managed by the responsible Directorate. The RCA for this patient is attached (appendix 1). It is difficult to be certain of the cause of the patient identification error. The experienced (Consultant) investigator concludes that the most likely cause to be a mistake whilst using the electronic requesting system (Notis). It is possible to open multiple pages whilst using this system and this has been highlighted as a potential cause for ordering an investigation on the incorrect patient as each open page will belong to a different patient. This type of error is often associated with trainee doctors engaged with caring for more than one patient at busy times.”

Source location

2015-0181-Response
Page 1 · response
Published 11 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

Strengthen induction training for new doctors on avoiding multiple open patient pages in the Notis system.

Verbatim wording from the response

“f. The NUH Information Technology department has previously highlighted the issue of multiple pages on Notis, and have strengthened the induction training of new doctors in this regard. An assessment of this issue has not provided a technological safeguard as potential barriers to this error were thought to create their own patient safety concerns.”

Source location

2015-0181-Response
Page 2 · response
Published 11 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

Update radiography checking procedures to assess clinical details and manage discrepancies.

Verbatim wording from the response

“k. The radiography report arrives at recommendations which has generated an Action Plan (appendix 3) managed by the Directorate. These actions are complete and include reflection by the member of staff involved and updating of checking procedures including assessment of the clinical details and how to manage discrepancies.”

Source location

2015-0181-Response
Page 2 · response
Published 11 May 2015

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

No technological safeguard for incorrect patient selection was implemented because potential barriers were considered capable of creating other patient safety concerns.

Verbatim wording from the response

“f. The NUH Information Technology department has previously highlighted the issue of multiple pages on Notis, and have strengthened the induction training of new doctors in this regard. An assessment of this issue has not provided a technological safeguard as potential barriers to this error were thought to create their own patient safety concerns.”

Source location

2015-0181-Response
Page 2 · response
Published 11 May 2015

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The incorrect-patient imaging error did not delay the correctly intended patient's investigation, which occurred before the erroneous attendance.

    Stated by Nottingham University HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The incorrect-patient imaging error did not delay the correctly intended patient's investigation, which occurred before the erroneous attendance.

Verbatim wording from the response

“a. The second area of concern within the PFD notice is the potential delay to diagnosis for the patient for whom the x-ray had been properly intended.”

Source location

2015-0181-Response
Page 2 · response
Published 11 May 2015

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