A U.K. coroner has specified that a dying woman had her cancer diagnosis delayed after radiology staff mistakenly scanned the wrong patient due to a failure to check the patient's identity.
Pamela Honeybone, 90, was admitted to Scarborough General Hospital in September 2024 after a fall. She was referred for a CT exam, but another woman, called Pamela, was scanned, and her results were attributed to Honeybone. A subsequent scan on Honeybone, which was performed four days before her death on 19 October, discovered an “abdominal mass suggestive of lymphoma,” according to a coroner's Prevention of Future Deaths report.
North Yorkshire coroner Catherine Cundy said it was not possible “on the balance of probabilities” to determine that the mistake contributed to Honeybone's death, which she attributed to a naturally occurring disease, BBC News reported. However, Cundy said the incident highlighted “matters giving rise to concern,” such as hospital staff failing to check the identity of patients.
“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,” she said. “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 coroner added.
The scanning error was recognized by 15 October, but it was not conveyed to the medical team treating Honeybone until late October, by which time her death had been assessed as natural, initially avoiding the need to be referred to a coroner, BBC News stated.
As a result of the delay, an investigation into the death did not begin until late November 2024. When the York and Scarborough Teaching Hospitals NHS Foundation Trust’s investigation eventually began, 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 investigation focused on nursing involvement, the article pointed out.
An action plan was drawn up after the investigation, but no audit of compliance with patient identification processes began until August 2025, 10 months after the patient’s death. The coroner said the results of the audit showed that one in five treatment encounters between staff still occurred without the patient being positively identified.
Radiology transfer checklists were routinely completed in normal working hours at Scarborough Hospital, but no such checklist was in use at the group's York site at any time of the day, BBC News stated. Honeybone's misidentification occurred “out of hours” at Scarborough, when no designated person assumed responsibility for this task at that site.
“There is a risk that future deaths could occur unless action is taken,” the coroner said, adding that by 19 November 2025, the hospital group must explain actions proposed or taken (or why no action had been taken) to avoid more deaths.
A spokesperson for the trust conveyed sincere condolences to the patient’s family, BBC News said.
“We recognise and share the concerns raised by the HM Coroner,” the spokesperson said. “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."
The York and Scarborough NHS Trust will be setting out a action plan and implementation timetable to meet the coroner's deadline, the spokesperson noted. "The trust takes patient safety seriously and endeavours to ensure lessons are learned,” the representative said.
