The scanning error was recognised by on 15 October, but was not conveyed to Mrs Honeybone’s treating team until late October, by which time her death had been assessed as natural, initially avoiding the need to be referred to a coroner.

As a result of the delay above, an investigation into the death did not begin until late November 2024. When the trust’s investigation started, staff 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 focused on nursing involvement.

An action plan was drawn up as a result of the investigation, but for various reasons no audit of compliance with patient identification processes began until August 2025 – 10 months after Mrs Honeybone’s death.

The coroner said the results of the audit indicated that one in five treatment encounters between staff of all grades and specialisms still occured without the patient being positively identified.

While radiology transfer checklists were routinely completed ‘in hours’ at Scarborough Hospital, no such checklist was 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 assumed responsibility for this task at that site.

Original source: gb