Coroner calls for action after radiology staff scans the wrong patient, fails to catch mistake

A radiology department in the United Kingdom is in hot water following a case of mistaken identity that resulted in a delayed diagnosis. 

In September of 2024, Pamela Honeybone, 90, presented to Scarborough General Hospital after a fall. She was admitted and later sent for a CT scan. Around that same time, another patient named Pamela was scanned under Ms. Honeybone’s name, which resulted in the incorrect results being filed under her chart. 

Honeybone was discharged but returned to the hospital in mid-October. At that point, she was scanned again; this led to the discovery of an "abdominal mass suggestive of lymphoma.” She passed away a few days after her scan, but nearly a year after her death, the hospital is still grappling with the mistakes that led to the missed finding. 

A coroner determined that it was highly unlikely that the mistake contributed to Honeybone’s death. However, the coroner acknowledged that the incident highlighted "matters giving rise to concern,” as it was later revealed that Honeybone came into contact with numerous staff members, including an emergency provider and CT tech, who failed to properly identify her. 

"No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself,” the coroner’s report noted. “No member of staff inquired as to the outcome of this patient's CT scan prior to her discharge a few hours later." 

It wasn’t until October 15, when the Honeybone returned to the hospital, that it was discovered her scan results had been filed under the wrong patient. However, her care team was not made aware of this until late October after she had passed, and nearly a year after the incident occurred, the hospital still has not taken steps to fully address the issue. 

An investigation into the incident started in November 2024. Following its conclusion, an action plan was drawn up, followed by an audit to ensure compliance in August 2025—10 months after the initial incident. The audit revealed that one out of every five staff members Honeybone came into contact with failed to properly identify her. The audit also identified several failures in processes that were put in place to avoid such mistakes. 

"In my opinion there is a risk that future deaths could occur unless action is taken,” the coroner suggested, advising the NHS trust to follow up with the hospital to ensure that appropriate steps have been taken to prevent similar incidents in the future.