Queen Elizabeth Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected. We also looked at systems and processes which kept people safe from harm.

At this assessment we rated this key question as good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well and lessons were learnt to continually improve practice. Staff told us when they reported incidents, they were usually involved in investigations and asked for their input. We saw evidence of multidisciplinary team (MDT) review of incidents and specific incident case review panel meeting minutes which demonstrated a holistic approach to incident review, understanding and development of learning. Staff told us they received feedback from incidents they reported, and they were involved in the development of learning post incidents which was shared in team meetings, huddles and by email. Staff told us they did not feel blamed and were not treated negatively when things went wrong. Staff told us they were supported by their managers and colleagues and were treated with understanding. They said lessons were learned from safety incidents and changes were made to reduce risks. Incidents were discussed at governance meetings. For example we saw within the minutes from the governance meetings review of shared learning about discrepancy on paediatric head CT and a missed fracture by a radiologist during a busy duty session

There were up-to-date policies and procedures to support incident investigation and duty of candour (being open and honest with patients when things went wrong). Staff understood the types of incidents that needed to be reported and the importance of duty of candour. In the 12 months prior to our assessment of the service there were no serious incidents, and no incidents relating to radiation that required reporting under Ionising Radiation (Medical Exposure) Regulations.

Leaders told us they encouraged staff to report all incidents to ensure risks could be identified and action taken. We observed and were told that there was a culture of prioritising patient safety and learning across the department. Staff told us they felt the service was responsive to concerns and there were processes in place to enable information to be shared with everyone in a timely way. Staff told us the teaching environment was positive and supportive, and they were encouraged to participate in training opportunities.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were clear processes to make sure that registered healthcare professionals who requested imaging as part of their routine or extended practice had the right training and authorisation to do so. Staff said that radiographers reviewed referrals to confirm that imaging was needed. A radiologist was available for advice through a “hot seat” system, and modality leads provided support when staff had questions.

‘Pause and check’ posters were in all imaging areas we visited. They were designed to act as a reminder of the checks that needed to be made when any diagnostic imaging examinations were being performed. However, they were not always the correct ‘pause and check’ poster for the area they were displayed in. For example, the ‘pause and check’ posters in the x-rays rooms were for referrers not for clinical imaging examination. We raised this matter with the service, and they were making progress with changing the posters during our assessment.

The service had appropriate local rules and employer procedures in place to restrict radiation exposure to staff and patients, and to support the safe use of ionising radiation. Where local rules were due for review, these had been completed. The service ensured that the radiation protection adviser (RPA) and the medical physics expert (MPE) were accessible and available to provide advice on radiation safety. Radiation protection supervisors (RPS) were in place in all departments where ionising radiation was used.

Staff understood the processes for escalating unexpected or significant findings identified during imaging examinations and reporting. Patients were provided with information about how and when they would receive the results of their imaging.

Outpatient and GP referrals were prioritised and appointments booked based on the urgency of the referral. The trust’s centralised booking team coordinated the booking of appointments using booking policies and exclusion criteria.

During our assessment on most occasions, we saw radiographers ensuring the other radiographer was behind the shield prior to initiating the X-Ray. However, on one occasion we witnessed an incident in which a radiographer pressed the X-ray button whilst another radiographer was only partially shielded. This was fed back to the leadership team who actioned this immediately. Feedback was given to the radiographer however it does demonstrate that some staff were not always following processes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service took appropriate steps to safeguard people from abuse and improper treatment. The service worked with people and relevant partners to understand what being safe meant to them and to promote a culture where people were protected from abuse, discrimination, harassment, avoidable harm, and neglect.

People using the service said they felt safe and well supported.

Staff had received appropriate safeguarding training for adults and children. The service monitored compliance with mandatory training, with over 96% of diagnostic imaging staff having completed safeguarding adults training and over 97% having completed safeguarding children training. Staff were able to recognise potential signs of abuse and knew how to raise concerns in line with local safeguarding procedures. They were able to explain the actions they would take to protect people at risk of harm or experiencing abuse.

Staff demonstrated an understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and 99% of staff had completed mandatory training in DoLS, MCA, and best interests. This supported staff to act in people’s best interests where there were concerns about a patient’s capacity. There had been no safeguarding concerns or referrals in the 12 months prior to the assessment.

The service had up‑to‑date safeguarding policies and procedures in place to protect adults and children from abuse and unsafe care. Safeguarding information was readily available for staff, who knew how to access policies, procedures, and safeguarding advice electronically.

Staff told us the safeguarding training they received supported them to identify concerns and gave them confidence to raise and escalate safeguarding issues appropriately.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where service provision was affected or disrupted at the location (for example, due to faulty equipment), the service took action to ensure people could access suitable alternative appointments at other locations belonging to the trust. The service had appropriate processes in place to respond to medical emergencies, and clinical staff had received training in basic life support. However, we raised concerns that reception staff without basic life support training were tasked with the oversight of patients in waiting areas. We raised this concern with the Trust during the assessment and were informed they are working to find a solution to this issue. The training data provided by the trust showed that there was variable rates of completion of basic life support training across the department and staff groups. Two groups of staff had not met the trust target of 90%, they were medical staff – radiology achieving 80% compliance and the ultrasound staff achieving 60% compliance.

Staff completed risk assessments for people using the service and responded appropriately when risks changed. People we spoke with were aware of the use of radiation and the associated risks. Clear information was displayed in all waiting areas explaining the benefits and risks of radiation exposure. Safety checks were completed, including checks to confirm pregnancy status, in line with regulatory requirements.

We observed staff following recognised safety guidance, including the Society of Radiographers’ “pause and check” process, to confirm patient identity and verify critical information before carrying out examinations or administering injections.

In MRI, staff completed forms to confirm patient identity and undertook comprehensive MRI safety screening for patients and any accompanying persons. Audit data showed staff were compliant with this process.

During the assessment, we observed staff consistently following safety protocols. Staff told us they could easily contact the radiation protection supervisor (RPS) and medical physics advisers for guidance on radiation protection when needed.

The service made reasonable adjustments to ensure care was delivered safely and accessibly, taking account of the different needs of people using the service.

On the whole the service detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we observed staff using equipment safely and appropriately. Clear signage was in place to warn people when ionising radiation was being used. Scanning and x-ray rooms were secure, with lockable doors to prevent unauthorised access, and were designed to protect staff and patients from unnecessary radiation exposure.

Staff wore radiation dose monitoring badges in designated areas, and the service monitored these to identify any risk of over‑exposure.

The service stored chemicals and substances hazardous to health safely and in line with guidance. Portable electrical equipment safety testing had been completed. Fire safety arrangements were in place, with clear evacuation routes and fire extinguishers stored appropriately. Staff understood their responsibilities in the event of emergencies, including fire or flood.

The service involved people in managing risks by providing accessible information about diagnostic imaging. Information posters were displayed in waiting areas explaining the risks and benefits of imaging procedures, including specific guidance for people who were pregnant

The service was registered with the Health and Safety Executive (HSE) to use ionising radiation and had effective systems in place to protect people from exposure. Staff completed routine quality assurance checks on imaging equipment to confirm it was safe for use. There were clear processes for reporting faults and requesting repairs, and staff understood the importance of reporting equipment concerns promptly. These arrangements supported the safe delivery of care and reduced the risk of harm to people using the service. Records showed that scanning and x‑ray equipment were serviced and maintained by approved third‑party providers to ensure they remained safe and fit for use.

Lead aprons and protective equipment were readily available, and routine checks were carried out to ensure they were safe to use. During the assessment, we identified two lead skirts and one lead apron that showed signs of wear or had not been hung correctly to avoid risk of unseen damage to internal not visible lead. The service acted immediately to address these concerns, which reduced the risk to people and staff.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service ensured there were enough qualified, competent, and experienced staff to deliver safe care and treatment. Staffing levels and skill mix were planned and reviewed to support safe care and to ensure staff did not work excessive hours. During the assessment, staffing levels and skill mix were in line with planned arrangements.

Staffing pressures were monitored and escalated through daily operational meetings, including morning huddle meetings, and the site team was kept informed of any staffing risks. At the time of the assessment, the diagnostic imaging department employed 152 staff, including consultant radiologists, medical staff, sonographers, radiographers, radiology department assistants, and administrative staff. There were 12.4 whole‑time equivalent consultant radiologists in post.

The service had effective processes to ensure staff who required professional registration, including with the Health and Care Professions Council (HCPC) and General Medical Council (GMC), held valid and appropriate registration. Recruitment records confirmed that all required pre‑employment checks had been completed, including enhanced Disclosure and Barring Service (DBS) checks.

The service had up‑to‑date policies to support safe recruitment and staff performance management. Staff received a structured induction and completed mandatory training relevant to their roles, including training on autism and learning disabilities. Systems were in place to monitor mandatory training compliance and to plan refresher training where it had expired. Staff received annual appraisals, which supported professional development and safe practice.

Sickness data provided for the diagnostic imaging department showed there was enough radiologists, radiographers, and support staff to meet service demand. Staff said they felt supported and reported they were able to manage workload safely with the current staffing levels.

At the time of the assessment, the service had been without a permanent general manager and head of imaging for an extended period, with interim arrangements in place. The trust had successfully appointed a general manager who was due to commence shortly. Although recruitment to the head of imaging role had not yet been successful, the trust was exploring interim secondment arrangements to support leadership and oversight. These arrangements had not adversely impacted the safe delivery of care.

The service had a comprehensive programme of development initiatives for radiographers during 2025/26. They were broken down into four groups: ‘A forever learning culture’, training governance, digital training and upskilling. Each group provided radiographers with opportunities to develop their practice. We received positive feedback from staff about these programmes. Data regarding the use of bank and agency staff was provided by the trust, it demonstrated the service used mainly bank staff to cover areas of short fall in staffing levels.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

During the assessment, the environment was visibly clean, tidy, and well maintained. Fixtures, fittings, and patient positioning foam pads were free from damage and designed to be easily cleaned. However, the vinyl covering on the table in the dual energy x-ray absorptiometry (DEXA) scanning room was cracked and could not be effectively cleaned. This was raised with the service during the inspection, and the trust provided assurance that a replacement cover had been ordered and that enhanced cleaning protocols had been implemented until the repair was completed.

The service promoted good hand hygiene. Clear signage was displayed throughout clinical areas, and hand sanitiser dispensers were readily available and adequately stocked. Handwashing facilities were accessible in clinical areas. Staff followed ‘bare below the elbow’ guidance and were observed carrying out hand hygiene and cleaning equipment appropriately between appointments. Personal protective equipment (PPE) was available in sufficient quantities to support safe practice.

Clinical waste was segregated, stored, and disposed of safely. We observed staff applying waste management procedures correctly. The service had processes in place to ensure the routine cleaning of the environment and equipment, and staff had received appropriate infection prevention and control training. Up‑to‑date policies were in place to reduce the risk of infection and support safe care delivery.

Sharps bins were available at the point of use and were assembled and used correctly. All sharps bins we observed were dated when first used and were temporarily closed when not in use, reducing the risk of sharps injuries.

The service involved people in managing infection risks. The booking process identified people with known or suspected infections so that appropriate appointment planning could take place. Staff told us people with infections were scheduled at the end of the day to reduce the risk of transmission and said they had sufficient time between appointments to complete enhanced cleaning. Staff were aware of who to contact for additional infection prevention and control advice. However, X-ray staff told us they frequently received patients who were infectious without prior notification or completion of the form and that this interrupted their lists.

Cleaning schedules were completed as planned and demonstrated that all areas were cleaned regularly. We observed “I am clean” stickers on equipment, which were in date and provided assurance to people that equipment had been appropriately cleaned. These arrangements supported safe care and minimised the risk of infection‑related harm.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had appropriate systems in place to ensure medicines, including contrast media, were prescribed, stored, and administered safely. Warming cabinets used to store contrast media were temperature‑controlled, with temperatures clearly displayed and routinely monitored. This helped ensure contrast media remained effective and reduced the risk of harm, including extravasation (the accidental leakage of contrast agents from a vein into surrounding tissue, rather than into the bloodstream).

We observed staff completing safety checks before all imaging procedures, including those involving contrast media. Staff completed appropriate documentation, which included recording relevant medical history, confirmation of consent, and details of cannulation. These checks supported the safe care and treatment of people using the service.

The service had patient group directions (PGDs) in place for radiographers and sonographers, which provided a safe and lawful framework for the administration of medicines within their scope of practice. We reviewed these PGDs and found they were up to date, version controlled and had been reviewed in line with organisational requirements.

Staff we spoke with demonstrated clear knowledge of the processes for recognising and responding to adverse reactions to contrast media. This supported timely intervention where needed and reduced the risk of avoidable harm to people.