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On 30 July 2025 an investigation was commenced into the death of Pamela Ann Honeybone, who died at Scarborough General Hospital on 19 October 2024 aged 90. The investigation concluded at the end of the inquest on 23 September 2025.  The conclusion of the inquest was that: Pamela Ann Honeybone died as a consequence of naturally occurring disease. Diagnosis of her condition was delayed when another patient was scanned in error instead of Mrs Honeybone, but it has not been possible to determine on the balance of probabilities that this contributed to her death.  On the 19 of September 2024 Pamela Ann Honeybone was admitted to Scarborough General Hospital following a fall. She required CT scanning but another patient with the same first name underwent the investigation in error and its results were attributed to Mrs Honeybone. Mrs Honeybone’s condition continued to deteriorate and a CT scan undertaken on the 15 of October 2024 revealed the presence of an abdominal mass suggestive of lymphoma. Mrs Honeybone was moved to end of life care and she died at the hospital on the 19 of October 2024. Matters of concern: It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient’s CT scan prior to her discharge a few hours later. The scanning error was recognised by a radiologist on the 15th of October 2024, but was not conveyed to Mrs Honeybone’s treating team until late October, by which time she had died and her death had been scrutinised by the Medical Examiner and certified by her treating doctor as wholly natural and not requiring referral to the Coroner. As a result of the aforementioned delay, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events. Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust Investigation focussed on nursing involvement with the patients in question and did not seek to identify and question medical team members. An Action Plan was drawn up as a result of the Trust Investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone’s death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified. The coroner heard evidence that while radiology transfer checklists are routinely completed ‘in hours’ at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust’s York site at any time of the day. Mrs Honeybone’s misidentification occurred ‘out of hours’ at Scarborough when no designated person assumes responsibility for this task at that site. The coroner considers the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.

Ambiguous or unnecessary radiologist recommendations for additional imaging (RAIs) can lead to excessive imaging use and diagnostic errors. The purpose of this paper was to determine the cumulative impacts of multifaceted technology-enabled interventions aimed at optimising RAI on RAI rate, actionability, and resolution over an 8-year period. Authors conclude that multifaceted interventions to optimize RAI improved the rate, actionability, and resolution of RAI.

This is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022.   Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services.  The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services.   This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care.   Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care.   Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60.  We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs.   Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions. Access the full census report here Related content: The benefits of a nursing led Vascular Access Service Team: A White Paper to outline a standardised structure and approach for the NHS to deliver vascular access services in every hospital (27 June 2022)  

The Care Quality Commission's (CQC) annual report on their work to enforce the Ionising Radiation (Medical Exposure) Regulations in England has been published. The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about these. The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2022 and 31 March 2023. The report also presents the key findings from our inspection and enforcement activity in that time. In 2022/23, CQC received 727 notifications of errors: 380 (52%) were from diagnostic imaging departments. 77 (11%) were from nuclear medicine departments. 270 (37%) were from radiotherapy departments. During this period, there were over 43 million diagnostic imaging examinations carried out on NHS patients in England. Of these, around 29 million used ionising radiation. There were also 142,000 episodes of radiotherapy treatment in England. This shows that notifications of errors represent a small proportion of the total examinations and treatment undertaken. Although notifications relate to incidents where there is risk of harm, most do not result in harm to patients. The most common cause of error was when images were requested for the wrong patient. We also found that inadequate checks about the patient’s identity or mistakes by the operator had resulted in errors. For some inspections, we made recommendations to providers to make improvements or took enforcement action in response to non-compliance with the regulations. Areas for improvement included: Ensuring a full set of procedures and guidance that reflects effective clinical practice to support staff when delivering care. More frequent testing of equipment. Maintaining up to date and accurate records for practitioners working in the service.

Exposure to ionising radiation during image guided procedures has been associated with a higher incidence of breast cancer in female healthcare workers. Lead or lead equivalent gowns are used to reduce radiation exposure during image guided procedures, but studies have shown that current gowns provide inadequate protection to breast tissue as they leave the upper outer quadrant and axilla exposed. Isobel Pilkington and colleagues discuss the risk and the steps that must be taken to ensure full protection of breast tissue in this BMJ Editorial.

This report shares findings from complaints made to Parliamentary and Health Service Ombudsman (PHSO) about failings in imaging in the NHS. The majority of these complaints involve people who had cancer at the time they used imaging services. Through highlighting these complaints, the PHSO’s objective is to support NHS services to improve. It suggests that failings in imaging services can only be addressed and learned from through collaboration across clinical specialties, looking at the whole imaging journey and its intersections as part of the patient’s care pathway. Findings The PHSO analysed 25 complaints relating to failings in the imaging journey since 2013. Most concluded between 2018 and 2020. This report focuses on four key findings they have seen in their casework Failure to follow national guidelines on reporting unexpected imaging findings. Failure to act on important unexpected findings. Delays in reporting imaging findings. Failure to learn from past mistakes. Recommendations For the system as a whole: Recommendations from previous work related to imaging must be implemented as a priority (referring to previous reports by the Healthcare Safety Investigation Branch, Care Quality Commission and the Independent Review of Diagnostic Services). Digital infrastructure must now be treated as a patient safety issue. Department of Health and Social Care and NHS England and NHS Improvement should ensure there is national guidance on the roles and responsibilities of clinicians, and expected timeframes, at each stage of the imaging journey. Department of Health and Social Care and NHS England and NHS Improvement should write to the Health and Social Care Select Committee and the Public Administration and Constitutional Affairs Committee by the end of March 2022. For imaging services specifically: All NHS-funded providers that have a radiology service should ensure staff working in those services have sufficient allocated time in their job plans for meaningful learning and reflection. Clinical directors and senior managers of NHS-funded radiology services should triangulate the learning from across their departments on a regular basis. The Royal College of Radiologists should review existing guidance on reporting unexpected findings and peer review of radiological reports to learn from the findings of PHSO’s casework.

Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. In recent years there has been an ongoing growth in demand for radiology services, especially MRI and CT. This pattern of growth is likely to continue as radiology is being used earlier and more widely in diagnostic pathways. This report recommends several measures aimed at maximising existing capacity and expanding services, including: reducing outpatient non-attendance by ensuring imaging can be arranged to suit the patient, through online booking and extended hours. opening day case units or beds for patients having interventional radiology procedures, to help prevent delays and hospital-acquired infections, and free up beds elsewhere. delivering faster results by increasing the amount of reporting carried out at home by radiologists and reporting radiographers. reducing the stress of delays by using artificial intelligence (AI) tools to support scheduling and prioritisation. Watch a short video summary of the report

The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk caused by delays in diagnosing lung cancer. Lung cancer is the third most common cancer diagnosed in England, but accounts for the most deaths. Two-thirds of patients with lung cancer are diagnosed at an advanced stage of the disease when curative treatment is no longer possible, a fact which is reflected in some of the lowest five-year survival rates in Europe. Chest X-ray is the first test used to assess for lung cancer, but about 20% of lung cancers will be missed on X-rays. This results in delayed diagnosis that will potentially affect a patient’s prognosis. The HSIB investigation reviewed the experience of a patient who saw their GP multiple times and had three chest X-rays where the possible cancer was not identified. This resulted in an eight-month delay in diagnosis and potentially limited the patient’s treatment options. The investigation: sought to understand the context and contributory factors influencing a delay in lung cancer diagnosis in a patient repeatedly attending primary care with non-specific symptoms. identified the systemic factors that help or hinder the detection of lung cancer on chest X-rays. considered the utility of chest X-ray to assess for lung cancer in symptomatic patients being seen in primary care. identified the implications of the findings for mitigating the risk of delayed diagnosis of lung cancer. Safety recommendations HSIB recommends that NHS England and NHS Improvement work with research partners to explore options for commissioning research to address whether low-dose computed tomography (CT) is clinically- and cost-effective for the diagnosis of lung cancer in symptomatic patients seen in primary care compared to chest X-ray. HSIB recommends that the National Institute for Health and Care Excellence (NICE) reviews its current safety netting advice to healthcare professionals with respect to the investigation of possible lung cancer. The wording of the advice should be amended as required to make it clearer what should be offered to patients with ongoing, unexplained symptoms who have had a negative chest X-ray. HSIB recommends that NHSX, in collaboration with relevant stakeholders such as The Royal College of Radiologists and The Society and College of Radiographers, develops guidance to support independent benchmarking and validation of artificial intelligence algorithms for the identification of lung diseases such as cancer.

Diagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.

In September 2015, the Institute of Medicine (IOM) issued the report “Improving Diagnosis in Health Care,” which focused on the underappreciated problem of diagnostic error in medicine. This report builds on the IOM’s 2000 landmark report, “To Err is Human”, which specifically highlighted opportunities for improvement in diagnostically focused fields, such as radiology and pathology. One of the major recommendations of the report is that “health care organizations should adopt policies and practices that promote a nonpunitive culture that values open discussion and feedback on diagnostic performance”. Notably, the report emphasises the ineffectiveness of traditional approaches to evaluating medical error that focus on identifying individuals’ errors. In this article published in Radiology, Larson and colleagues review the recommendations set forth by the recent IOM report, discuss the science and theory that underlie several of those recommendations, and assess how well they fit with the current dominant approach to peer review. They also offer an alternative approach to peer review: peer feedback, learning, and improvement (or more succinctly, “peer learning”), which they believe is better aligned with the principles promoted by the IOM.