Lives at risk due to medical scan mistakes, says ombudsman

Repeated failures in how CTs, X-rays and different medical scans are being interpreted are resulting in avoidable affected person deaths and delays in diagnosing most cancers, England’s well being ombudsman has warned.

The commonest issues embody docs failing to identify abnormalities, scans being delayed or not carried out, and outcomes not being adopted up correctly.

The ombudsman has upheld or partially upheld 45 circumstances which embody failures in medical imaging within the final 4 years, and says classes have to be realized to keep away from the identical errors once more.

NHS England stated workers work extraordinarily laborious to maintain sufferers protected however acknowledged there was extra to do to enhance the “response to severe well being points”.

In a single case, medical workers at Wexham Park Hospital in Slough repeatedly did not diagnose an 82-year-old man with bowel most cancers and left him struggling extended ache, in response to the parliamentary and well being service ombudsman (PHSO).

The person, from Buckinghamshire, went to A&E 5 occasions between August and October 2021.

A scan taken in August confirmed a lesion within the bowel.

Nonetheless, clinicians reported no abnormalities, the investigation discovered, resulting in a six-week delay in analysis and surgical procedure.

The affected person additionally had an X-ray in October that steered an obstruction in his small bowel, however this X-ray was not reviewed and he was discharged and despatched dwelling.

Later that month the most cancers was recognized and he had an operation to take away a part of the bowel. The surgical procedure uncovered one other mass elsewhere in his physique.

Simply months later, the person took his life, leaving a observe saying he might now not cope with the ache.

The ombudsman, Rebecca Hilsenrath KC, stated workers did not handle his ache on 5 events.

Failings in his care “had been most likely contributory components to the affected person’s resolution to finish his life”, her report suggests.

The person’s daughter stated: “I actually tried to get the docs to hear.

“I had a sense one thing was incorrect and I pleaded quite a few occasions for them to maintain him within the hospital, however they only stored discharging him and never doing something to assist him.”

An announcement offered by the hospital belief says: “We’re very sorry for our failing in care on this case and now we have an additional assembly with the affected person’s household shortly to replace them on the modifications now we have since made.

“This contains guaranteeing that older sufferers presenting with stomach ache are appropriately reviewed.”

The belief has additionally agreed to pay the household £4,000, as beneficial by PHSO.

In one other investigation, the ombudsman discovered a cancerous tumour was incorrectly recognized as benign (non-cancerous) – regardless of repeated scans suggesting in any other case.

The affected person, a 54-year-old man, had his first scan in Tenerife, after changing into unwell on vacation.

His brother stated: “When my brother collapsed in Tenerife, the hospital instantly recognized the tumour for what it was [an aggressive brain tumour] and even provided to take away it.

“However my brother wished to return dwelling, he thought the most effective place for him to have the remedy was within the NHS.”

The person returned to Gillingham, the place the native hospital carried out additional scans figuring out the tumour, and referred him to specialists at King’s School Hospital.

Nonetheless, workers there “downgraded the analysis”, saying the tumour was not cancerous. The person was not provided chemotherapy or radiotherapy.

He died in hospital, a month after an operation to take away the tumour, which was confirmed to be cancerous.

If the most cancers had been recognized accurately, he might have had surgical procedure months earlier and doubtlessly the choice of chemotherapy and radiotherapy, PHSO stated.

Whereas the survival fee for this most cancers is poor, the ombudsman’s investigation suggests the person might have had a number of further months of life.

His brother stated: “I wished King’s School Hospital to acknowledge their errors in order that I can cease selecting on the scab of attempting to know what occurred to him and bear in mind my brother as he was when he was alive.”

In an announcement, King’s School Hospital NHS Basis Belief stated: “We absolutely recognise that errors had been made on this affected person’s care, and we apologised to his household on the time of the incident.

“Studying from errors after they happen is essential, and now we have made quite a lot of modifications because of this case to enhance the protection and effectiveness of the care our groups present.”

The belief has agreed to pay the household £3,500.

Ms Hilsenrath, whose group independently investigates complaints, stated: “Every of the circumstances now we have investigated and upheld characterize an actual individual whose life has been impacted by failings in care.

“They’re additionally all cases the place the organisations concerned did not establish that something had gone incorrect”

The 2021 ombudsman report into medical imaging points beneficial system-wide enhancements, however Ms Hilsenrath stated whereas there had been some progress, she was nonetheless seeing cases the place folks’s care was “sub-optimal, usually with devastating penalties”.

It’s “essential” that motion is taken to enhance the digital infrastructure within the NHS and guarantee persons are recognized and handled swiftly, she added.

Dr Katharine Halliday, president of the Royal School of Radiologists, agreed digital infrastructure wanted enhancements.

“The ombudsman highlights some devastating failures within the NHS, and we should collectively study from these experiences to drive significant change,” she stated.

“Nonetheless, it should even be recognised that these findings mirror a system that’s overburdened and under-resourced.”

The school says it faces a 30% shortfall of scientific radiologists, which is projected to rise to 40% by 2028.

An NHS spokesperson stated: “The NHS had delivered a document variety of exams and checks in 2024, a fifth greater than pre-pandemic however we all know there may be extra to do to enhance the popularity and response of great well being points.”

A Division of Well being and Social Care spokesperson stated: “Our deepest sympathies are with all those that have been affected by the failings highlighted on this surprising report.”

The spokesperson added that they had been opening extra Group Diagnostic Centres (CDCs), and utilizing new know-how like AI so “all sufferers can obtain world-class care”.

Modifications had been additionally being launched in most cancers care, the spokesperson stated, which might see 100,000 extra sufferers who’re referred receiving a analysis inside 4 weeks and as much as 19,000 extra folks beginning their remedy inside two months annually.