PFD report

Sandra Rhoda Marion Wood · Prevention of Future Deaths report

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Issued 12 Feb 2016•North West Kent

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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. Lack of weekend facilities for routine CT scans
    Part of recurring concern: Failure to provide timely access to clinically indicated CT scanningPart of recurring concern: Unreliable timeliness of radiology imaging and reporting
  2. Lack of a specific application procedure for urgent CT scans
    Part of recurring concern: Failure to provide timely access to clinically indicated CT scanningPart of recurring concern: Failure to provide timely urgent diagnostic investigations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.

    Stated by Maidstone and Tunbridge Wells NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Lack of weekend facilities for routine CT scans

Wider context from the report

“(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to clinically indicated CT scanning; Unreliable timeliness of radiology imaging and reporting.

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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

Lack of a specific application procedure for urgent CT scans

Wider context from the report

“(1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends (2) If an urgent CT scans are necessary a specific application procedure has to be put in place (3) In this case despite the requirements for an urgent scan to be undertaken in a potentially emergency situation the scan was to be delayed until after the weekend, which proved to be too late due to the fact that Mrs Woods died on Saturday 18th April 2015. ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to clinically indicated CT scanning; Failure to provide timely urgent diagnostic investigations.

Open source report

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

Existing out-of-hours CT access procedures and consultant escalation arrangements are considered sufficient for obtaining urgent scans when clinically required.

Verbatim wording from the response

“Without rehearsing my response, I am happy to assure you that there is sound reasoning behind our procedure. Patients fall under the care of consultants, but spend more time being actively treated by junior doctors. To ensure that patients are appropriately escalated for treatment of a worsening condition (in the full knowledge of the treating consultant) it is necessary to ensure that a consultant is aware when a patient is to be sent for a CT scan at all times. On weekdays when consultants are more readily available on-site within the Trust these referrals are less noticeable than out of hours or on weekends, but the procedure is always in place.”

Source location

sandra-wood-Response
Page 2 · response
Published 12 February 2016

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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 Trust disputes that weekend CT facilities are unavailable, stating emergency scans are provided without numerical restriction based on clinical need.

Verbatim wording from the response

“1) The NHS Trust does not have facilities for routine CT scans to be carried out during weekends.”

Source location

sandra-wood-Response
Page 1 · response
Published 12 February 2016

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.1

  1. 1

    Reiterate to clinical staff that urgent CT scanning is available 24/7 when clinically indicated, regardless of day or time.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Consultants retain responsibility for deciding whether CT scanning has sufficient clinical net benefit under radiation safety requirements.

    Stated by Maidstone and Tunbridge Wells NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The Trust disputes that this patient's clinical presentation warranted an urgent CT scan, citing examination, imaging, blood and urine findings.

    Stated by Maidstone and Tunbridge Wells NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Reiterate to clinical staff that urgent CT scanning is available 24/7 when clinically indicated, regardless of day or time.

Verbatim wording from the response

“In this particular case the evidence provided by Drs Nguyen, Ibrahim and Smith indicated that the clinical presentation of Mrs Woods did not merit an urgent CT scan; Mrs Wood had no bowel distension, her bowel was soft and non-tender on examination and her x-ray results (which would highlight signs of obstruction) were unremarkable, as were her blood and urine test results. However, the Trust has taken the opportunity to re-iterate the processes in place to clinical staff regarding the availability of CT scanning 24/7 for urgent cases.”

Source location

sandra-wood-Response
Page 2 · response
Published 12 February 2016

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

Consultants retain responsibility for deciding whether CT scanning has sufficient clinical net benefit under radiation safety requirements.

Verbatim wording from the response

“I think it is helpful to highlight that CT scans are only one diagnostic tool of many at our disposal and, in accordance with s.6 of The ‘Ionising Radiation (Medical Exposure) Regulations 2000’ (IR(ME)R) we are required to justify that there is sufficient net benefit (when weighed against the risks of radiation exposure) before scanning a patient. Given the level of skill required and repercussions of unwarranted scans, the responsibility for that decision rests with our consultants.”

Source location

sandra-wood-Response
Page 2 · response
Published 12 February 2016

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

The Trust disputes that this patient's clinical presentation warranted an urgent CT scan, citing examination, imaging, blood and urine findings.

Verbatim wording from the response

“In this particular case the evidence provided by Drs Nguyen, Ibrahim and Smith indicated that the clinical presentation of Mrs Woods did not merit an urgent CT scan; Mrs Wood had no bowel distension, her bowel was soft and non-tender on examination and her x-ray results (which would highlight signs of obstruction) were unremarkable, as were her blood and urine test results. However, the Trust has taken the opportunity to re-iterate the processes in place to clinical staff regarding the availability of CT scanning 24/7 for urgent cases.”

Source location

sandra-wood-Response
Page 2 · response
Published 12 February 2016

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