Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0485, written 25 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Sep 2025 |
|---|---|
| Reference | 2025-0485 |
| Deceased | Pamela Honeybone |
| Coroner | Catherine Cundy |
| Coroner area | North Yorkshire and York |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | York and Scarborough Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 York and Scarborough Teaching Hospitals NHS Foundation Trust 1 CORONER I am Catherine CUNDY, Area Coroner for the coroner area of North Yorkshire and York 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 30 July 2025 I commenced an investigation into the death of Pamela Ann HONEYBONE 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. CIRCUMSTANCES OF THE DEATH 4 On the 19th 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 15th 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 19th of October 2024. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. 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. 2. 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 OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 3. As a result of the delay at 2 above, 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. 4. 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. 5. 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. 6. I 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. 7. I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 19, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Department of Health & Social Care - Prevention of Future Death Reporting who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 25/09/2025 Catherine CUNDY Area Coroner for North Yorkshire and York OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Executive Office
York Hospital
Wigginton Road
York
YO31 8HE
Andre Bertram, Interim Chief Executive
Ms C Cundy
HM Area Coroner for North Yorkshire & York
Dear Madam
Thank you for raising your concerns following the inquest surrounding the death of Pamela
Honeybone regarding her admission to Scarborough Hospital in September 2024. York &
Scarborough Teaching Hospitals NHS Foundation Trust (the Trust) recognises the
seriousness of your concerns outlined at Section 5 of the Report to Prevent Future Deaths
(PFD). I write to outline the actions we have taken to address these. These measures are
intended to reduce the risk of recurrence and improve the quality and safety of care provided
to our service users.
On review of your concerns, we have grouped these into four areas for response.
1.
Nonadherence to the Patient Identification process
The Trust has an Identification of Patients policy in place. This has recently been reviewed
and findings from this case have been used to strengthen adherence to the identification
process.
In addition, it is reassuring to note, in relation to the audit results presented at inquest by
Matron
, there has been a significant improvement in positive patient identification in
more recent audits following Trust wide communication reminding staff of the importance of
positive patient identification. This policy is also subject to regular audit to confirm
compliance.
2.
Radiology transfer checklists not in place across the Trust
The action in the Patient Safety Incident Investigation (PSII) report to standardise the
radiology transfer checklist is almost complete. It was acknowledged that the CT transfer
checklist in place at the time of Mrs Honeybone’s admission was not robust and not in place
across the Trust. It was agreed that a transfer checklist was needed for all radiological
investigations, not just CT scans. The checklist has been drafted and reviewed in consultation
with the wider Radiology and nursing team and a final draft is awaiting sign off at the
Radiology Governance Board. The checklist is due to be published and deployed for use at
the end of November 2025.
Radiographers will be empowered to decline investigations if the checklist is not complete.
This will be monitored at the Radiology clinical governance meetings and escalated to the
Cancer Specialist & Support Services Care Group Board.
3.
Identification of radiological error not immediately conveyed to the treating
team
When a potential identification error is identified it is usual to report this on the Datix incident
system. Initial investigations then take place to establish whether an error has occurred. Once
an error is confirmed the treating clinician is advised of this and asked to consider any harm
attached to the error and notify the patient of this in line with our Duty of Candour obligations.
This process can take some time, but it is preferable for the initial investigation to be
concluded before the findings are conveyed to a patient. We do however acknowledge that in
this case this meant the treating team were not aware of the incorrectly attributed images
prior to Mrs Honeybone’s death and this resulted in a delay in referring the death to HM
Coroner.
Going forward, where a discrepancy is identified, this will be reported via Datix ideally within
24 hours. Incidents are reviewed daily by Care Group governance teams and therefore can
ensure the relevant clinical team will be made aware of a potential issue within 24hrs during
the working week and 72hrs, at worst, over the weekend period. This will alert to the need for
multidisciplinary discussion and investigation.
All reporting teams will be reminded regularly at Radiology meetings, and discrepancy
meetings, of the need to initiate this Datix when they are aware of any confirmed patient
identification errors discovered during reporting. However, implementation of the transfer
checklist will improve compliance with the patient identification standard operating procedure
(SOP) across all patients attending imaging from the Emergency Department and inpatients.
4.
Delay in more detailed investigation
We acknowledge that there was some delay in further investigations being carried out into the
circumstances of the radiological error and this meant valuable witness evidence was not
included. At the time of Mrs Honeybone’s death the Trust was in the early stages of
implementing the Patient Safety Incident Response Framework (PSIRF). This framework is
now embedded and if a similar incident occurred it would be likely that a hot debrief or after-
2
action review would take place in a timelier manner, to include all relevant staff in discussions
about the incident.
We hope that this information provides you with assurance that the Trust has learned from
this incident and refined our processes as a result. This will continue to be monitored carefully
through our governance and assurance structures.
Yours sincerely
Interim Chief Executive
3
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