Pamela Honeybone

“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 [name redacted] 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.”

“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 [name redacted] 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.”

“I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.”