This week the Parliamentary and Health Service Ombudsman (PHSO) published a report about failings associated with medical imaging, how this is reported and how findings are communicated and followed up.
They identified four themes in the cases that they reviewed:
- failure to follow national guidelines on reporting unexpected imaging findings
- failure to act on important unexpected findings
- delays in reporting imaging findings
- failure to learn from past mistakes.
Sadly these issues are not limited to cases which have been reported to the Ombudsman. At Freeths we have investigated a number of clinical negligence cases where findings have been made on x-rays or scans but these have not been acted upon or communicated to the patient. Our clients have only discovered the issue at a later date, for example when the condition had worsened and they required emergency care.
Knowing that information was available to clinicians but nothing has been done, and that they have missed opportunities to receive earlier treatment, causes additional distress and worry to patients at a time when they are already having to come to terms with their diagnosis.
Problems with the communication of x-ray and scan findings have been the subject of other reports including the Healthcare Safety Investigation Bureau (HSIB) whose report was published in July 2019. This report found that there was wide variation in how unexpected radiological findings were communicated and that systems were not always clear or robust.
It is clear that more can be done to prevent these failings from happening and the Ombudsman has urged the Government to make improving imaging services and their interaction with other parts of the NHS a priority. Imaging is an important diagnostic tool and it is vital that the causes of these avoidable errors are addressed as soon as possible.
If you or a loved one have suffered an injury as a result of delays or failings in reporting on an x-ray or scan, then our specialist medical negligence solicitors may be able to help. Please contact a member of our national clinical negligence team for a free, confidential discussion:
Carolyn Lowe, Partner (Oxford/London/Bristol/Milton Keynes) on 0186 578 1019 firstname.lastname@example.org
Karen Reynolds, Partner (Derby/Stoke on Trent/Birmingham/Manchester/Liverpool) on 0845 274 6830 email@example.com
Jane Williams, Partner (Nottingham/Leicester/Sheffield/Leeds) on 0845 272 5724 firstname.lastname@example.org
When imaging errors occur along the patient pathway, they compound the negative impact on the patient and their family. For many patients, there were missed opportunities to be diagnosed earlier or have more appropriate treatment that may have prolonged their life. In the most serious case, there was an avoidable death. Families told us they experienced great distress because the outcome for their loved one could have been different if these failings had not happened.