PFD report

Kathleen Stewart · Prevention of Future Deaths report

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Issued 17 Jul 2022•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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised4

  1. Failure to identify incident learning from what went wrong
    Part of recurring concern: Inadequate safety incident investigations
  2. Failure to assess the fitness of the Emergency Department system for acting on abnormal clinical imaging reports
  3. Failure to act on abnormal clinical imaging reports and provide indicated follow-up
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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

    Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.

    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 27 September 2022.
  2. Action

    Repeat the radiology governance audit on a six-month rolling programme, including compliance with the new SOP.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  3. Action

    Audit radiology findings using a large random sample to assess Emergency Department fracture identification and follow-up actions.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.

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

  1. Position

    The incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustNo action considered necessaryThe respondent said that 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

Failure to identify incident learning from what went wrong

Wider context from the report

“1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:- a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 assess the fitness of the Emergency Department system for acting on abnormal clinical imaging reports

Wider context from the report

“1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:- a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 act on abnormal clinical imaging reports and provide indicated follow-up

Wider context from the report

“1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:- a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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 assess whether problems acting on abnormal clinical imaging reports are broader than an isolated incident

Wider context from the report

“1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus; It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy; 2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:- a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident; b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging. ”

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

Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.

Verbatim wording from the response

“In addition to this, a planned monthly focus on incident reporting is currently underway across the organisation and being led by the Assistant Director of Integrated Governance throughout September, culminating in the Trust’s Patient Safety Conference on October 6th 2022. This programme of events and activities seeks to engage staff at all levels and focuses on identification of incidents or near misses, incident reporting, acting on and learning from incidents.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022

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

Repeat the radiology governance audit on a six-month rolling programme, including compliance with the new SOP.

Verbatim wording from the response

“It is our intention to repeat this audit on a six month rolling programme and this will include standards to measure compliance with the new SOP as detailed in the section one of this response. This specific audit has also been added to the Trust Audit plan which is overseen at the Service Quality and Assurance Group and the Quality and Governance Committee.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022

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

Audit radiology findings using a large random sample to assess Emergency Department fracture identification and follow-up actions.

Verbatim wording from the response

“The investigation was informed by an audit of radiology findings, using a large random sample from June 2022. In respect of Emergency Department clinicians identifying fractures, the audit found that the Trust scored favourably when compared to the National average (3.1%, compared to 3.7% Nationally). The audit also identified that the small number of fractures not identified by Emergency Department clinicians were all acted upon appropriately when the report was received from a Radiologist or Reporting Radiographer.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022

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 the Incident Reporting and Incident and Complaint Investigation Policy against the NHS England Patient Safety Framework.

Verbatim wording from the response

“It is considered that this could have been handled differently, with improved triangulation. Detailed action to improve this have been outlined to you in my letter of 11th August 2022 and you are aware that the Trust’s Incident Reporting, and Incident and Complaint Investigation Policy is currently being reviewed alongside the NHS England Patient Safety Framework to ensure that this aligns. The policy will outline the process for identifying, reporting, managing, investigating and learning from patient safety incidents. The purpose of this review of policy is to support a systematic, compassionate and effective response to patient safety incidents; with a clear focus on learning and continuous improvement. This work will ensure accountability, compassion, openness and ownership of improvement and will provide a basis for local training and development.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022

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

Complete a retrospective multidisciplinary learning review of the incident and identify learning from the case.

Verbatim wording from the response

“As a result of your concerns outlined above, the Trust has undertaken a retrospective concise investigation into Mrs Stewart’s case in the form of an Multi Disciplinary Team (MDT) learning review involving Urgent Care and Radiology.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022

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

Introduce and test an electronic RAG-priority radiology reporting and alerting system for Emergency Department findings.

Verbatim wording from the response

“Whilst the Trust has current safety net procedures in place, we are working to introduce a system whereby a Radiologist or Reporting Radiographer will be able to immediately assign a level of priority to each report in the Radiology reporting system, CRIS. This will be completed using a using a Red-Amber-Green (RAG) rating.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 27 September 2022

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

Require Consultant review on the day for specified X-rays received by the Emergency Department before 22:00.

Verbatim wording from the response

“The audit will be used to inform future teaching sessions for junior doctors; providing additional education in respect of pubic rami, lumbar spine and thoracic spine X-Rays. These X-Rays will also be reviewed by a Consultant on the day of performance where received by the Emergency Department prior to 22:00 hours. This is intended to reduce the occasions on which injuries are not identified by doctors within the Emergency Department.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022

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

Hold a multidisciplinary learning event and share learning from the case to support prevention of harm and improve future patient experience.

Verbatim wording from the response

“I hope that this provides you with assurance that this matter has been taken seriously with a commitment to improve and learn from these events. In addition to this, in September 2022, Mrs Stewart’s case will form part of a multidisciplinary learning event being held by the Trust. We will seek to share the learning from Mrs Stewart’s case in order to prevent harm to, and improve the experience of, future patients. Inevitably, this will include a focus on incident reporting, which supports our aims outlined earlier in this letter.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 5 · response
Published 27 September 2022

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

Implement a reporting and escalation SOP covering responsibilities, documentation, monitoring, oversight and escalation of unread or unacknowledged findings.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) has been developed to support the roll out of this new electronic capability, which provides an explanation of the reporting and escalation process and outlines the clinical responsibilities of both Radiology and Emergency Department colleagues. The SOP includes monitoring and oversight arrangements to ensure compliance with the process. The SOP also provides clear guidance on the need to record action taken in relation to any abnormal results identified after the patient has left the Department, this will be recorded in the patient’s electronic notes. The automated alerting system will also have the capability to escalate any un-read or un-acknowledged radiology findings to operational and clinical leads for action.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 27 September 2022

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 and monitor daily Emergency Department Consultant review of radiology reports, with administrative processing of required actions.

Verbatim wording from the response

“In the interim, to mitigate risk Emergency Department Consultant reviews of all radiology reports received within the Department is being prioritised and is being monitored on a daily basis by the Urgent Care Clinical Director and Associate Divisional Director, overseen by the Medicine and Urgent Care Divisional Quality and Safety Board. For those radiology reports where an action is required the Emergency Department Consultants work with the Urgent Care”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 2 · response
Published 27 September 2022

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 incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.

Verbatim wording from the response

“The MDT learning panel noted that a review of Mrs Stewart’s care by the Learning from Deaths Team was undertaken in December 2021. The Learning from Deaths Team identified concerns that the family and care home had not been informed of the fractured pubic rami and an incident form was completed, in accordance with Trust guidelines. At that time, work was ongoing to improve results governance within the organisation; with collaboration between Urgent Care, Radiology and the Clinical Information Team. There was a risk on the Urgent Care Risk Register in relation to results governance, with mitigation and further action recorded. Following a discussion with the Emergency Department’s Clinical Director, the incident was closed, with no further action identified. It is apparent that operational pressures as a result of our Covid-19 response impacted upon our oversight of this.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022

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

An audit found that the small number of fractures missed by Emergency Department clinicians were acted upon appropriately when radiology reports were received.

Verbatim wording from the response

“The investigation was informed by an audit of radiology findings, using a large random sample from June 2022. In respect of Emergency Department clinicians identifying fractures, the audit found that the Trust scored favourably when compared to the National average (3.1%, compared to 3.7% Nationally). The audit also identified that the small number of fractures not identified by Emergency Department clinicians were all acted upon appropriately when the report was received from a Radiologist or Reporting Radiographer.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022

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.2

  1. 1

    Circulate incident trigger lists organisation-wide and remind Emergency Department Consultants to report missed abnormal results as incidents.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
  2. 2

    Provide additional junior-doctor teaching on identifying pubic rami, lumbar spine and thoracic spine X-ray injuries.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.

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

Circulate incident trigger lists organisation-wide and remind Emergency Department Consultants to report missed abnormal results as incidents.

Verbatim wording from the response

“As a result of your concerns outlined above in relation to incidents, the Trust’s incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting. Emergency Department Consultants have been specifically reminded of the need to report as an incident any missed abnormal results.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 4 · response
Published 27 September 2022

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

Provide additional junior-doctor teaching on identifying pubic rami, lumbar spine and thoracic spine X-ray injuries.

Verbatim wording from the response

“The audit will be used to inform future teaching sessions for junior doctors; providing additional education in respect of pubic rami, lumbar spine and thoracic spine X-Rays. These X-Rays will also be reviewed by a Consultant on the day of performance where received by the Emergency Department prior to 22:00 hours. This is intended to reduce the occasions on which injuries are not identified by doctors within the Emergency Department.”

Source location

Response from NHS Tameside and Glossop Integrated Care
Page 3 · response
Published 27 September 2022

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