The BBC has this week reported that England’s health ombudsman has warned that repeated failures in how CT scans, x-rays and other medical scans are being interpreted are leading to avoidable patient deaths and delays in diagnosing cancer.
Repeated mistakes
Back in 2021, the ombudsman prepared a report that highlighted mistakes in the way digital images were read and used as a diagnostic tool.
Since that report, the ombudsman has upheld or partially upheld 45 cases in which there were failures in medical imaging in the last four years. These were similar findings to those warned about in their 2021 report.
The most common problems include failing to spot abnormalities, scans being delayed or not carried out at all, and results not being followed up.
Examples of the impact of these failings include a case involving a 10-month delay in cancer being diagnosed, which significantly harmed the patient’s chance of survival.
In another case, serious pelvis sepsis was missed and not diagnosed, which led to an avoidable death.
Another example seen by the ombudsman involved a missed ankle fracture, which led to an avoidable operation.
The ombudsman has warned that lessons must be learned to avoid the same mistakes happening again.
Devastating consequences
Rebecca Hilsenrath, KC, parliamentary and health service ombudsman, said:
“When things go wrong, there must be learning at both an organisational and wider systemic level. In our 2021 report we recommended a system-wide programme of improvements for more effective and timely management of x-rays and scans. Whilst we have seen some progress in this area, unfortunately we are still seeing instances where people’s care is sub-optimal, often with devastating consequences.
“It is critical that action is taken to improve the digital infrastructure of the NHS and make sure people are correctly diagnosed and swiftly treated. NHS leaders need to address this as the important patient safety issue it is.”
An overburdened and under-resourced system
President of the Royal College of Radiologists (RCR), Dr Katherine Halliday, said:
“The ombudsman highlights some devastating failures in the NHS, and we must collectively learn from these experiences to drive meaningful change. However, it must also be recognised that these findings reflect a system that is overburdened and under-resourced.”
The RCR says it has faced a 30% shortfall of clinical radiologists.
A spokesperson for the Department of Health and Social Care said:
“Our deepest sympathies are with all those who have been affected by the failings highlighted in this shocking report.”
They added that they were opening more Community Diagnostic Centres and using new technology so patients could receive “world-class care”.
Comment
It is shocking to read that, even after warnings given 4 years ago in 2021, there continue to be the same failings happening time and again.
This is putting lives at risk and cannot continue.
It is imperative now that changes are made to ensure that safe and effective care is the standard that patients can expect.
How can we help?
Danielle Young is a Legal Director in our Medical Negligence team, which has been ranked in tier one by the independently researched publication, The Legal 500.
If you have any questions in relation to the subjects discussed in this article, then please get in touch with Danielle or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
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