PFD report

Alfred Jones · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 24 Apr 2021•Manchester South

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Shortage of qualified radiology staff
    Part of recurring concern: Insufficient radiology workforce capacity for timely imaging and interpretation
  2. Insufficient MRI scanner capacity and availability
    Part of recurring concern: Unreliable access to timely MRI scanning
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.10

  1. Action

    Develop an expanded imaging workforce, including increased radiographer and radiologist training, new Imaging Training Academies and innovative imaging technologies.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.
  2. Action

    Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
  3. Action

    Increase imaging equipment capacity in England to address diagnostic service demand.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.

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

  1. Position

    Each integrated care system’s workforce team is responsible for delivering local imaging workforce priorities.

    Stated by NHS Greater Manchester Integrated Care BoardRedirects 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

Shortage of qualified radiology staff

Wider context from the report

“1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”

Is this part of a recurring concern?

Yes — Insufficient radiology workforce capacity for timely imaging and 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

Insufficient MRI scanner capacity and availability

Wider context from the report

“1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. ”

Is this part of a recurring concern?

Yes — Unreliable access to timely MRI scanning.

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

Develop an expanded imaging workforce, including increased radiographer and radiologist training, new Imaging Training Academies and innovative imaging technologies.

Verbatim wording from the response

“From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

Source location

2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 2021

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

Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.

Verbatim wording from the response

“From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

Source location

2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 2021

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

Increase imaging equipment capacity in England to address diagnostic service demand.

Verbatim wording from the response

“From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.”

Source location

2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 2021

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 community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.

Verbatim wording from the response

“Funding within the 2021/22 spending review has been targeted to support diagnostics via the development of community diagnostic hubs which will in turn augment access for inpatient activity in acute hospital services through the movement of elective activity to community settings. It is anticipated that MRI, CT scanning, Ultrasound and X-ray services will be the core imaging offer for these new centres and will represent new additional imaging capacity.”

Source location

2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 2021

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 the Greater Manchester Imaging Network to coordinate regional imaging workforce and infrastructure development.

Verbatim wording from the response

“Regional Collaboration and infrastructure to address the shortfall A Greater Manchester Imaging Network has been established, and there are several examples of interventions taking place across GM to address the imaging workforce challenges. However, it has been agreed that a regional approach should be taken which has resulted in the three NW Imaging Networks working collaboratively to develop a NW Imaging Workforce Strategy (out for consultation until 12/6/21).”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021

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

Increase the substantive radiologist workforce and establish additional advanced reporting and sonographer capacity.

Verbatim wording from the response

“Since this time, investment has been made to increase the clinical workforce, increasing the number of substantive Radiologist from three to five with a further two undertaking the CESR qualification (Certificate of Eligibility for Specialist Registration), there are also 3 locum consultants bringing a total establishment to 8.5 whole time equivalent. This is an increase of 3.5 in the last 18 months. In addition to this there is also a Consultant Sonographer and 5 Advance Practice Reporting Radiographers.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021

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 five-year North West imaging workforce implementation plan to guide local implementation plans for the three integrated care systems.

Verbatim wording from the response

“To support delivery of the strategy, a NW implementation plan for the next 5 years will be developed, which will inform the local implementation plans for the three ICS.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 3 · response
Published 5 May 2021

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 the North West Imaging Workforce Strategy through collaboration among the three regional imaging networks.

Verbatim wording from the response

“Regional Collaboration and infrastructure to address the shortfall A Greater Manchester Imaging Network has been established, and there are several examples of interventions taking place across GM to address the imaging workforce challenges. However, it has been agreed that a regional approach should be taken which has resulted in the three NW Imaging Networks working collaboratively to develop a NW Imaging Workforce Strategy (out for consultation until 12/6/21).”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021

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

Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.

Verbatim wording from the response

“Tameside and Glossop Integrated Care NHS FT At the time of Mr Jones’ referral, Tameside and Glossop Integrated Care NHS Foundation Trust (T&GIC FT) was sourcing additional scanner capacity by provision of a mobile MRI scanner. This was implemented on 20th September 2020, offering additional outpatient scanning capacity for 12 hours per day, 7 days per week. The mobile MRI van is still used currently to provide additional capacity. It is also worth noting that the Trust did not reduce or delay suspected cancer patient scans due to the pandemic, and therefore, the MRI scanner was being fully utilised.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021

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

Prioritise Diagnostic Radiography in Greater Manchester Allied Health Professions career events during 2021–22.

Verbatim wording from the response

“Activity to promote Radiography as a career choice Throughout the year several activities take place where Allied Health Professions career are showcased and promoted to our communities in GM. We are committed to prioritising Diagnostic Radiography during career events in 21/22.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 3 · response
Published 5 May 2021

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

Each integrated care system’s workforce team is responsible for delivering local imaging workforce priorities.

Verbatim wording from the response

“Health Education England NW (HEE) has commissioned a programme of work to support and progress Diagnostic Radiographer (DRAD) workforce planning priorities across the region, through scoping activities and targeted actions/interventions. This will ultimately provide a North West (NW) imaging workforce framework and strategy. Although the overall approach is regional, each ICS has its own workforce team that will be required to deliver on local workforce priorities.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 2 · response
Published 5 May 2021

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.4

  1. 1

    Establish Imaging Networks across England to improve imaging service resilience, care quality and patient access.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.
  2. 2

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
  3. 3

    Present and share the case learning with the Greater Manchester Quality Board.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
  4. 4

    Share the learning with Greater Manchester service commissioners for consideration within commissioned services.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.

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

Establish Imaging Networks across England to improve imaging service resilience, care quality and patient access.

Verbatim wording from the response

“The National Imaging Strategy published in November 2019 also sets out the case for the development of Imaging Networks across England and work is now well underway to establish these new operating models to support increased service resilience, quality of care and improved patient access.”

Source location

2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 5 May 2021

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

Monitor key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 4 · response
Published 5 May 2021

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

Present and share the case learning with the Greater Manchester Quality Board.

Verbatim wording from the response

“1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 4 · response
Published 5 May 2021

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

Share the learning with Greater Manchester service commissioners for consideration within commissioned services.

Verbatim wording from the response

“2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission”

Source location

2021-0135-Response-from-GMCA-GMHSCP-Redacted
Page 4 · response
Published 5 May 2021

Open published response
Back to top

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