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 embrace medical doctors 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 embrace failures in medical imaging within the final 4 years, and says classes have to be discovered 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 didn’t diagnose an 82-year-old man with bowel most cancers and left him struggling extended ache, in line with 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 house.

Later that month the most cancers was identified 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 notice saying he might now not take care of the ache.

The ombudsman, Rebecca Hilsenrath KC, stated workers didn’t handle his ache on 5 events.

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

The person’s daughter stated: “I actually tried to get the medical doctors to pay attention.

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

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

“This consists of guaranteeing that older sufferers presenting with belly 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 supplied to take away it.

“However my brother needed to come back house, he thought the most effective place for him to have the therapy 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 Faculty Hospital.

Nonetheless, workers there “downgraded the analysis”, saying the tumour was not cancerous. The person was not supplied 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 probably 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 needed King’s Faculty Hospital to acknowledge their errors in order that I can cease choosing 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 Faculty Hospital NHS Basis Belief stated: “We totally 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 once they happen is essential, and we have now made quite a lot of modifications on account 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 crew independently investigates complaints, stated: “Every of the circumstances we have now investigated and upheld symbolize an actual particular person whose life has been impacted by failings in care.

“They’re additionally all situations the place the organisations concerned didn’t establish that something had gone fallacious”

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 situations the place individuals’s care was “sub-optimal, typically with devastating penalties”.

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

Dr Katharine Halliday, president of the Royal Faculty 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 replicate a system that’s overburdened and under-resourced.”

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

An NHS spokesperson stated: “The NHS had delivered a document variety of assessments 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 individuals beginning their therapy inside two months annually.