PFD report

Khadija Kerri · Prevention of Future Deaths report

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Issued 25 Feb 2025•South Yorkshire (Eastern)

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
5

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. Lack of a clear internal procedure for disseminating external radiology addendum reports to the treating clinical team
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

    Upload the approved failsafe communication protocol to the Trust intranet for staff access.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2025.
  2. Action

    Audit failsafe notifications within three months of protocol implementation to verify appropriate communication and management.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2025.
  3. Action

    Complete the review of the radiological findings communication protocol.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 February 2025.

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

  1. Position

    The referrer remains responsible for reading and acting on radiology reports; the failsafe protocol does not replace that clinical responsibility.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of a clear internal procedure for disseminating external radiology addendum reports to the treating clinical team

Wider context from the report

“There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team. If this is not addressed there is potential for similar delays and incorrect management of patient care. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Upload the approved failsafe communication protocol to the Trust intranet for staff access.

Verbatim wording from the response

“Once fully approved and ratified, the protocol will be uploaded onto the Trust’s intranet within the Policies & Procedures section which is accessible by all staff. It is important to note this is a Trust-wide Policy which provides further enhancement to the safety of our patients on all hospital sites.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 27 February 2025

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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

Audit failsafe notifications within three months of protocol implementation to verify appropriate communication and management.

Verbatim wording from the response

“In accordance with the Trust’s approved policy procedure, the Failsafe protocol will be audited within 3 months of implementation to ensure all “Failsafe notifications” are communicated and managed appropriately.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 27 February 2025

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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

Complete the review of the radiological findings communication protocol.

Verbatim wording from the response

“I would like to take this opportunity of assuring you and Ms Kerri’s family that the Trust has undertaken a full review of the Failsafe Alert for Radiological Findings (Communication Protocol) PAT/T 38 v.5 and this is scheduled to be duly approved through the Local Clinical Governance processes by the 4 June 2025. Our Radiology department communicated with Everlight Radiology to ensure their full agreement with”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 27 February 2025

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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

Obtain governance approval and ratification of the amended failsafe communication protocol.

Verbatim wording from the response

“I would like to take this opportunity of assuring you and Ms Kerri’s family that the Trust has undertaken a full review of the Failsafe Alert for Radiological Findings (Communication Protocol) PAT/T 38 v.5 and this is scheduled to be duly approved through the Local Clinical Governance processes by the 4 June 2025. Our Radiology department communicated with Everlight Radiology to ensure their full agreement with”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 27 February 2025

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 referrer remains responsible for reading and acting on radiology reports; the failsafe protocol does not replace that clinical responsibility.

Verbatim wording from the response

“Whilst it is recognised that this revision is essential to ensure patient safety, it is acknowledged that the safety net contained within the protocol does not replace the Referrer’s responsibility to read and act upon radiology reports. This is in line with national guidance “Recommendations on Alerts and Notification of Imaging Reports”, published by the Academy of Medical Royal Colleges October 2022.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 27 February 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.1

  1. 1

    Regularly communicate referrers’ responsibility to read and act on radiology reports through Trust governance processes.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 February 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

Regularly communicate referrers’ responsibility to read and act on radiology reports through Trust governance processes.

Verbatim wording from the response

“Whilst it is recognised that this revision is essential to ensure patient safety, it is acknowledged that the safety net contained within the protocol does not replace the Referrer’s responsibility to read and act upon radiology reports. This is in line with national guidance “Recommendations on Alerts and Notification of Imaging Reports”, published by the Academy of Medical Royal Colleges October 2022.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 27 February 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