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Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

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August 4, 2021

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.