A scanning error at the NHS Scarborough Hospital led to the delayed cancer diagnosis of Pamela Honeybone, who later died, after another woman called Pamela’s results were attributed to her
A 90-year-old woman’s cancer diagnosis was delayed after hospital staff mistakenly scanned the wrong person due to the patients having the same first name.
Pamela Honeybone needed a CT scan at the NHS Scarborough Hospital in North Yorkshire following a fall, but another patient with the same first name underwent the investigation in error – and its results were attributed to her. A coroner has identified six concerns surrounding the treatment of the elderly woman, and the way the hospital investigated what happened.
North Yorkshire coroner Catherine Cundy sent a Prevention of Future Deaths report to the Trust in order to prevent similar incidents happening again. The coroner said that Mrs Honeybone had died from a natural disease and that a diagnosis of her condition was delayed due to the scanning error, although it was not possible to determine that this had contributed to her death at the hospital on October 19, 2024.
The report says that Mrs Honeybone was admitted on September 19 and needed a CT scan but another patient with the same first name was scanned instead. Her condition deteriorated and a CT scan was undertaken on October 15 which revealed an abdominal mass suggestive of lymphoma. She was then moved to end of life care, YorkshireLive reports.
The coroner identified six concerning issues:
- 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 October 15 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 delay, a Trust investigation did not commence until late November 2024. No prompt after action review 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 by the Trust, 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 indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified
- While radiology transfer checklists are routinely completed ‘in hours’ at Scarborough Hospital when a dedicated HCA (healthcare assistant) 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 concluded: “I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.”
The coroner has asked the Trust to respond by November 19. In a statement, a spokesperson from York and Scarborough Teaching Hospitals NHS Foundation Trust said: “The Trust would like to convey sincere condolences to Mrs Honeybone’s family. We recognise and share the concerns raised by the HM Coroner.
“Following the conclusion of the inquest, we acknowledge that the coroner has called on us to take further steps, and we fully take that on board.
“We will be setting out our action plan and implementation timetable to meet the coroner’s deadline. The Trust takes patient safety seriously and endeavours to ensure lessons are learned.”