Report exposes ongoing mistakes with diagnostic scans
Patients are being harmed or have died because scans are misread, delayed or not followed up, according to a new report out today by the Parliamentary and Health Service Ombudsman (PHSO).
The report, comes in the same week that NHS England (NHSE) published new guidance to trusts recommending they automatically send verified scan results directly to patients via the NHS App, four weeks after they have taken place
The PHSO says it has partly or fully upheld more than 40 complaints, following a report published four years ago highlighting similar mistakes in the way digital images are read and used as a diagnostic tool.
Tragic impacts include:
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an 82-year-old whose bowel cancer was missed despite a scan and repeated visits to A&E at Wexham Park Hospital. He endured extensive pain and took his own life.
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a 53-year-old man who died from an aggressive brain cancer after doctors at King's College London, who had scanned him, misdiagnosed the tumour as benign. Surgery and treatment was delayed by nine months, and shortened the time he had left to live.
The PHSO is calling for greater learning from mistakes.
The new NHSE guidance says waiting four weeks before sending results direct to patients, would give time for the referring clinician to receive any abnormal results and advise the patient on next steps, but also act as a safeguard if usual administration processes did not work. People not signed up to the NHS App would be contacted via their clinician.
NHSE acknowledges in the guidance that there is work to do to simplify medical terminology that would be sent with scan results and that a disclaimer should always be sent advising patients to go back to their referring clinician about any questions they have.
The new NHSE guidance says waiting four weeks before sending results direct to patients, would give time for the referring clinician to receive any abnormal results and advise the patient on next steps, but also act as a safeguard if usual administration processes did not work. People not signed up to the NHS App would be contacted via their clinician.
NHSE acknowledges in the guidance that there is work to do to simplify medical terminology that would be sent with scan results and that a disclaimer should always be sent advising patients to go back to their referring clinician about any questions they have.