PFD report

Richard David ROE · Prevention of Future Deaths report

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Issued 22 Oct 2024•Cambridgeshire and Peterborough

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
2

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 method for ensuring clinician review of routine CT scan reports
    Part of recurring concern: Unreliable review of diagnostic imaging before consequential care decisions
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.2

  1. Action

    Produce monthly reports identifying unviewed routine radiology scans using the current radiology system.

    Stated by North West Anglia NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2024.
  2. Action

    Improve the electronic records system to include requested reports and enable tracking of report viewing.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2024.

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

  1. Position

    Clinicians who request routine scans and their departments remain primarily responsible for reviewing reports.

    Stated by North West Anglia 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 method for ensuring clinician review of routine CT scan reports

Wider context from the report

“(1) The evidence revealed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians. This is despite a similar occurrence in May 2021. The inquest heard that the Trust are investigating a new IT System which will be able to flag when such issues occur. However this is a medium/long term project with no current completion date known and there is no system in place at present to prevent a repeat of such an incident. ”

Is this part of a recurring concern?

Yes — Unreliable review of diagnostic imaging before consequential care decisions.

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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

Produce monthly reports identifying unviewed routine radiology scans using the current radiology system.

Verbatim wording from the response

“However, as you note, the implementation of the improved records system is some way off and as an interim measure we’ve reviewed the abilities of the current radiology system and it can, and will, produce reports of unviewed scans (initially monthly) which can then be followed up with the requesting clinicians and/or their departments. The ability of the present system to provide information in detail is limited and at the moment it will identify a large number of unviewed images (most of which would be expected and not a concern) but in liaison with the external providers of the system we expect to be able to refine the information to better identify any scans that have been overlooked.”

Source location

Response by North West Anglia NHS Foundation Trust
Page 1 · response
Published 24 December 2024

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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

Improve the electronic records system to include requested reports and enable tracking of report viewing.

Verbatim wording from the response

“The Trust is in the process of improving its electronic records system so that it is comprehensive and includes all reports requested by clinicians including radiology reports. This is a substantial financial investment by the Trust both in terms of the technology and the staff time needed to implement it. The details of the system haven’t yet been finalised but it will give the Trust more management and audit options and it is expected to include an easier ability to track the viewing of all types of reports including those for routine radiology scans.”

Source location

Response by North West Anglia NHS Foundation Trust
Page 1 · response
Published 24 December 2024

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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

Clinicians who request routine scans and their departments remain primarily responsible for reviewing reports.

Verbatim wording from the response

“Reviewing scan reports appropriately and timeously has always been, and will remain, the primary responsibility of the clinicians who requested them and/or their departments. However that failed for Mr Roe and we accept that there needs to be a system to ensure that routine scans aren’t overlooked which isn’t dependent on individual clinicians or their departments.”

Source location

Response by North West Anglia NHS Foundation Trust
Page 1 · response
Published 24 December 2024

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