A 90-year-old woman's hospital diagnosis was "delayed" before her death after medical professionals carried out a CT scan on the wrong patient, a coroner has said.

Pamela Ann Honeybone required the scan after being admitted to Scarborough Hospital following a fall on September 19, 2024.

"But another patient with the same first name underwent the investigation in error and its results were attributed to Mrs Honeybone," area coroner Catherine Cundy wrote in a report following Mrs Honeybone's death.

The coroner said it had "not been possible to determine on the balance of probabilities that this [the delay] contributed to [Mrs Honeybone's] death".

A York and Scarborough Teaching Hospitals NHS Foundation Trust spokesperson said it recognised and shared "the concerns raised by the coroner".

The spokesperson for the trust, which runs Scarborough Hospital as well as York Hospital, said it "takes patient safety seriously and endeavours to ensure lessons are learned".

Following an inquest, the coroner concluded that Mrs Honeybone died as a "consequence of naturally occurring disease".

Mrs Honeybone underwent a CT scan on October 15, 2024, which found "abdominal mass suggestive of lymphoma [cancer]", the coroner's report said.

She was moved to end of life care and died at the hospital four days later.

Ms Cundy wrote to the York and Scarborough Teaching Hospitals NHS Foundation Trust following the inquest held into Mrs Honeybone's death, saying "action should be taken" by the trust to "prevent future deaths".

The coroner said it was "accepted in evidence" during the inquest 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 [Mrs Honeybone]".

"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 said Mrs Honeybone's "misidentification" happened 'out of hours' at Scarborough Hospital "when no designated person assumes responsibility for this task at that site".

Ms Cundy said the "scanning error" had been recognised by a radiologist on October 15, 2024.

But, the coroner said, the error was "not conveyed to Mrs Honeybone's treating team until late October, by which time she had died and her death had been scrutinised by the medical examiner and certified by her treating doctor as wholly natural and not requiring referral to the coroner".

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Ms Cundy said the delay in reporting the error meant a trust investigation did not start until November 2024, adding: "When the trust investigation did commence, staff directly involved either could not be identified or had no recollection of events."

She said the results of the trust's investigation "indicate that one in five audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified".

The trust must respond to the coroner by November 19.

Its spokesperson said: "The trust would like to convey sincere condolences to Mrs Honeybone's family.

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

"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."