1. Purpose
This policy sets out how the Service records, escalates, communicates and follows up incidental findings identified during imaging.
It aims to make sure that clinically important findings do not depend on informal memory, individual goodwill or a single untracked message.
2. Sources to verify before adoption
- RCR standards for interpretation and reporting of imaging investigations: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/standards-for-interpretation-and-reporting-of-imaging-investigations-third-edition/
- RCR recommendations on alerts and notification of imaging reports: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/recommendations-on-alerts-and-notification-of-imaging-reports/
- Society of Radiographers professional guidance and publications: https://www.sor.org/
- SoR and BMUS Guidelines for Professional Ultrasound Practice: https://www.bmus.org/media/resources/files/_2023_SoR_and_BMUS_guidelines_8th_Ed_FINAL.pdf
- GMC Good Medical Practice: https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good-medical-practice
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: https://www.legislation.gov.uk/uksi/2014/2936/regulation/20
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
3. Scope
This policy applies to:
- findings outside the indication for the scan
- unexpected findings found during acquisition
- urgent or clinically significant findings in a report
- obstetric ultrasound findings outside the expected scan purpose
- sonographer, radiographer and radiologist escalation
- referrer communication
- patient communication where direct disclosure is appropriate
- follow-up confirmation
- failure to communicate or action an incidental finding
The policy applies to self-pay, private, insured and NHS-contracted patients.
4. Incidental finding process
The Service records every clinically relevant incidental finding and follows it through to documented communication or documented transfer of responsibility.
4.1 Identifying an incidental finding
An incidental finding is a finding outside the clinical question or purpose of the scan.
Examples include:
- suspected malignancy identified on an examination requested for another reason
- unexpected vascular, renal or abdominal finding
- suspected fetal anomaly identified during a direct-to-consumer obstetric scan
- clinically significant musculoskeletal or neurological finding outside the referral question
- unexpected device, foreign body or post-operative complication
Staff do not dismiss a finding because it is outside the booked scan package.
4.2 Urgency category
The reporter or senior clinician assigns an urgency category according to local protocol.
The local category set covers:
- critical finding needing immediate action
- urgent finding needing prompt clinical review
- significant finding needing planned follow-up
- minor or non-urgent finding recorded in the report only
The Service defines these categories locally against current RCR, SCoR and specialty guidance. This template does not invent response deadlines.
4.3 Referrer communication
The Service communicates urgent or significant findings to the referring clinician or agreed responsible clinician.
The communication record includes:
- finding summary
- urgency category
- name and role of person contacted
- contact route
- date and time
- advice given
- follow-up action requested
- confirmation that the report was sent
- failed contact attempts
Where the patient self-referred and no referrer exists, the Service follows its direct-to-patient and onward-referral pathway.
4.4 Patient communication
The Service tells the patient only within the role, competence and local protocol that applies to the examination.
Patient communication may include:
- explaining that the scan has identified something needing clinical review
- advising the patient to contact their GP, midwife or named clinician
- arranging urgent referral or emergency care where local protocol requires it
- providing written signposting where appropriate
- avoiding unsupported diagnosis beyond the reporter's scope
Staff do not give false reassurance where a finding needs follow-up.
4.5 Obstetric and direct-to-consumer scans
For obstetric scans, the Sonographer follows the local fetal-anomaly escalation pathway.
The pathway records:
- scan purpose
- finding or concern
- whether the scan was diagnostic or reassurance-only
- patient communication
- named NHS or private maternity route advised
- urgent referral route where required
- written information given
- follow-up confirmation attempt
The Service checks current professional guidance before adoption because direct-to-consumer obstetric scanning carries specific communication risk.
5. Follow-up confirmation
The Service keeps a follow-up tracker for urgent and significant incidental findings.
The tracker records:
- patient identity
- examination and date
- finding summary
- urgency category
- referrer or responsible clinician
- report sent date and time
- direct communication date and time
- follow-up action requested
- confirmation received
- failed contact attempts
- escalation where confirmation is not received
The Service closes the tracker only when communication has been documented or the Registered Manager has recorded a decision that responsibility has been transferred.
6. Incident response
The Service treats a missed, delayed or uncommunicated incidental finding as an incident.
The incident review considers:
- whether the finding was visible at acquisition
- whether the report identified the finding
- whether the report was sent
- whether urgent communication was required
- whether the patient was told within the local pathway
- whether the referrer acted on the finding
- whether harm occurred or could have occurred
- whether duty of candour applies
- whether the process needs a fail-safe improvement action
The Service records the incident under the relevant category, including incidental_finding_not_actioned where the taxonomy is available.
7. Responsibilities
- Registered Manager: owns this policy, ensures follow-up governance is reviewed and signs off annual review.
- Radiologist: owns clinical reporting standards, urgency categorisation and escalation for radiologist-reported examinations.
- Sonographer: escalates findings within scope, follows the obstetric pathway where relevant and records patient communication.
- Radiographer: escalates unexpected findings seen during acquisition and follows local urgent communication procedure.
- Reporting practitioner: records the finding, urgency category and communication requirement.
- Administration staff: send reports, record contact attempts and maintain the follow-up tracker where delegated.
- All staff: record concerns promptly and do not rely on informal verbal handover alone.
8. Recording requirements
The Service keeps the following records:
- examination record
- report
- incidental finding category
- urgency category
- referrer communication record
- patient communication record
- report transmission record
- follow-up tracker
- failed contact attempts
- duty of candour assessment
- complaint link where applicable
- incident record
- improvement action record
Records are kept in the Service governance records and linked to the patient record where relevant.
9. Audit cadence
The Service uses the following Verivius default audit rhythm unless current RCR, SCoR, GMC, CQC or local source material requires a different rhythm:
- Per urgent or significant finding: Staff record communication and follow-up status.
- Weekly: the assigned lead checks open follow-up tracker items.
- Monthly: the Radiologist or Lead Sonographer reviews urgent finding communication and report transmission exceptions.
- Quarterly: the Registered Manager reviews incidental finding themes, failed contact attempts, complaints and incidents.
- Annually: the Service audits the pathway against current source material and updates the category set.
Audit findings are recorded as improvement actions with an owner and review date.
10. Version control and review date
The Service keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Examination record
- Imaging report
- Urgent findings communication log
- Incidental findings follow-up tracker
- Complaint register
- Incident register
- Duty of candour policy
- Safeguarding policy
- Improvement action register
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.