Woman's cancer missed after wrong patient scanned

A woman about to undergo a CT scan (Stock image)

A dying woman had her cancer diagnosis delayed after hospital staff mistakenly scanned the wrong patient due to them having the same first name.

Pamela Honeybone, 90, was admitted to Scarborough General Hospital in September 2024 following a fall and later recommended for a CT scan.

But another woman called Pamela was scanned and her results attributed to Mrs Honeybone. A later scan on Mrs Honeybone, which took place four days before her death on 19 October, discovered an "abdominal mass suggestive of lymphoma", a coroner's report has revealed.

York and Scarborough Teaching Hospitals NHS Foundation said it "takes patient safety seriously" and would be setting out an action plan.

In a 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 Mrs Honeybone's death, which she attributed to a "naturally occuring disease".

However, she said the incident highlighted "matters giving rise to concern", such as hospital staff not checking the identity of patients.

The hospital trust apologised and said it would "endeavour lessons are learned"

"It was accepted in evidence that 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," the coroner's report 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 report also said:

• 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.

The coroner added: "In my opinion there is a risk that future deaths could occur unless action is taken."

She said the trust should explain actions proposed or taken - or why no action had been taken - to avoid more deaths, by 19 November 2025.

'Action plan'

A spokesperson from York and Scarborough Teaching Hospitals NHS Foundation Trust said they would like to convey sincere condolences to Mrs Honeybone's family.

"We recognise and share the concerns raised by the HM Coroner," they 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.

"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."

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