PFD report

HAROLD PENNY · Prevention of Future Deaths report

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Issued 24 Nov 2014•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.

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Concerns
2

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 raised2

  1. Failure to require radiology to urgently report findings to treating clinicians
    Part of recurring concern: Unreliable coordination of radiology services between healthcare teamsPart of recurring concern: Unreliable radiology processes for communicating findings and initiating required follow-up
  2. Failure to require radiology to rectify identified problems where possible
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

    Review the Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
  2. Action

    Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
  3. Action

    Review frameworks for tracking and following up all radiology reports and ensure they are robust.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.

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 require radiology to urgently report findings to treating clinicians

Wider context from the report

“There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible, nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of radiology services between healthcare teams; Unreliable radiology processes for communicating findings and initiating required follow-up.

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 require radiology to rectify identified problems where possible

Wider context from the report

“There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible, nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Review the Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.

Verbatim wording from the response

“Department examinations the same day. Where there are urgent findings (where medical evaluation is needed within 24 hours) the expectation will be that these are reported within four hours, the time frame depending on the nature of the imaging findings. Priority is given to inpatients, urgent requests and unexpected significant findings. The Trust’s objective is to document significant radiological findings and ensure they are communicated in a timely and unequivocal fashion. The Trust is reviewing its IT infrastructure to ensure this support is in place.”

Source location

2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 24 November 2014

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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

Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.

Verbatim wording from the response

“Work is being undertaken in this area at the Trust as part of the Sign up to Safety campaign which was launched by the Secretary of State for Health on 24 June 2014 with a mission to strengthen patient safety in the NHS. A draft ‘Radiology Requesting and Reporting Policy’ has been produced by the Trust and is currently going through our governance procedures.”

Source location

2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 1 · response
Published 24 November 2014

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

Review frameworks for tracking and following up all radiology reports and ensure they are robust.

Verbatim wording from the response

“As set out above, the policy that we are in the process of ratifying, places a great deal of responsibility with the Radiologists within the Trust. However, it is important to note the responsibilities of the referring clinicians also. It is their responsibility to ensure that they have in place a robust system to enable tracking and follow up of all radiology reports. One of the focus areas of the RGSG is to review frameworks for tracking and follow up of all radiology reports and ensure these are robust. Once received, reports should be legibly signed, dated and filed in a permanent patient record with a clear indication of any action taken following receipt of the report. It is the responsibility of the referring clinician to ensure this takes place and individual systems in place will be subject to regular audit.”

Source location

2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 4 · response
Published 24 November 2014

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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

Operate the Results Governance Steering Group to implement and continuously improve results-governance processes, with monthly meetings.

Verbatim wording from the response

“A Results Governance Steering Group (RGSG) was also developed in October 2013 and is one of ten project teams that report to the Tameside Hospital Patient Safety Programme Board (PSPB) as part of the ‘Keeping patients safe and reducing harm’ programme. The RGSG met for the first time on 4 November 2014 and is concerned with ensuring that the Trust has clinical and operational processes to adequately support effective results governance. The scope of this group is to ensure that effective results governance processes are in place to timely recognition and escalation of abnormal clinical results. The 2014-2015 objectives of this group specifically include improving the standards of results governance from both a report and service delivery perspective. The group has completed an initial review of processes and is now meeting monthly to ensure implementation and continuous improvement.”

Source location

2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014

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

    Disseminate the final radiology policy to staff through consultants, all-acute email and the Trust intranet, requiring staff familiarisation.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.

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

Disseminate the final radiology policy to staff through consultants, all-acute email and the Trust intranet, requiring staff familiarisation.

Verbatim wording from the response

“The draft radiology policy, referred to above, will be reviewed in the Results Governance Steering Group meeting in February 2015. The finalised policy will be brought to the attention of staff by Lead Consultants and will be circulated by way of an ‘all acute’ email and will be available on the Trust intranet. Staff will receive notification that a new policy has been uploaded to the intranet which they will then be required to familiarise themselves with.”

Source location

2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014

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