Patients are being put at risk because of blunders linked to NHS imaging services, a damning new report suggests.
Failures associated with X-rays and scans mean that some patients are not being told about serious illnesses, including cancer, until it is too late.
The Parliamentary and Health Service Ombudsman (PHSO) examined 25 complaints relating to failings in NHS imaging services dating back to 2013.
The Ombudsman’s new report highlights missed opportunities for patients to be diagnosed earlier or have treatment that may have prolonged their life.
One patient died after failures in the system led to their lung cancer going undiagnosed for three years.
The failings outlined in this report show that without a concerted effort to improve imaging, patient safety continues to be at risk.
PHSO Rob Behrens,
X-rays, CTs or MRI scans are a routine part of healthcare and can either guide treatment or dismiss any concerns.
Sometimes one of these tests will come up with unexpected findings but these are not always reported or acted upon, the report highlights.
For instance, one patient was being treated for breast cancer in August 2017 when a scan showed signs of pancreatic cancer.
The radiologist did not raise concerns and the patient was not diagnosed with pancreatic cancer until February 2019 – a delay of 18 months.
“There were several missed opportunities to diagnose the cancer earlier, which might have led to different or more effective treatment options that could have prolonged the patient’s life,” the report states.
The PHSO also said that some trusts were not learning from past mistakes.
In one case a patient was diagnosed with lung cancer three years after their first chest X-ray which indicated they may have the disease.
The patient had a chest X-ray in July 2014 and again in May 2015, but the cancer was not detected on either scan and the patient was instead treated for stroke-like symptoms.
The PHSO found that had the patient been treated after the first X-ray, then they could likely have survived.
The report also raised concerns about communication between health staff, which had “significant consequences for patients”.
For instance, emergency action should have been taken after a radiologist identified a “critical” unexpected finding – a patient with a hole in their oesophagus – but the report was sent via fax and it took a day before the scan was examined by the doctor who requested the scan.
Another blunder meant that a patient was unable to see their son before they died.
The patient had an X-ray through an NHS-funded subcontractor which did not pick up on unexpected findings.
A GP requested a follow-up CT scan which revealed the patient had terminal inoperable lung cancer and should have started palliative care six weeks previously.
The PHSO report states: “Several opportunities were missed to inform the patient of their diagnosis.
“This meant the patient could not discuss their prognosis with their doctor or family, make informed decisions about treatment and their quality of life, get their affairs in order or see their son before they died. This was a significant service failure.”
A third of the cases examined were found to have some sort of delay.
In one case, the findings from an MRI scan were not acted on for two months because the locum radiologist who originally viewed the scan did not complete the reporting of it.
The delay meant that liver cancer was diagnosed late and by the time the patient was diagnosed they were too poorly to start treatment.
The failures are system-wide and not limited to imaging services, the report adds.
The problems were identified across hospital services and GP practices and highlighted “infective communication” and an “absence of clear policies for the handover of care”.
The PHSO called on the Government to make sure that NHS imaging was put at the heart of the Covid-19 recovery plan.
Ombudsman Rob Behrens said: “X-ray and scan results are key to diagnosis and treatment for many people. Yet the failings outlined in this report show that without a concerted effort to improve imaging, patient safety continues to be at risk.
“Now, as the NHS recovers from the devastating impact of the pandemic, we have a vital opportunity to learn from the failings and embed system-wide changes to improve imaging in the health service.
“The evidence-led recommendations I have set out should be implemented swiftly, with collaboration across Government and the health sector to strengthen the NHS’s recovery.”
Dr Jeanette Dickson, president of the Royal College of Radiologists (RCR), said: “Hospital imaging teams are under more pressure than ever, battling through Covid backlogs on top of spiralling demand for radiology scans and procedures, and it is crucial that any system and local-level efficiencies that can happen, do.
“Staff desperately need breathing space to implement systems change, but this will only take us so far.
“Latest RCR staffing data shows the NHS needs at least another 2,000 radiologists to meet demand and ensure safe practice.”