Patients being harmed by repeated mistakes in reading scans

Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s health ombudsman has warned.

Since the publication of a report in July 2021, which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld 45 cases in which similar failings were found.

Rebecca Hilsenrath KC, parliamentary and health service ombudsman, said: “When things go wrong, there must be learning at both an organisational and wider systemic level.

“In our 2021 report we recommended a system-wide programme of improvements for more effective and timely management of X-rays and scans.

“While we have seen some progress in this area, unfortunately we are still seeing instances where people’s care is sub-optimal, often with devastating consequences.

“It is critical that action is taken to improve the digital infrastructure of the NHS and make sure people are correctly diagnosed and swiftly treated. NHS leaders need to address this as the important patient safety issue it is.”

The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up.

Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival.

In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation.

The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made.

Dr Katharine Halliday, president of the Royal College of Radiologists told Digital Health News: “We were deeply saddened to read of these cases.

“The Ombudsman highlights some devastating failures in the NHS, and we must collectively learn from these experiences to drive meaningful change.

“At the Royal College of Radiologists we are committed to supporting learning – we support radiologists directly with guidance and educational resources, and through our REAL initiative – which includes a platform where clinicians can submit anonymous cases that others could learn from, as well as an annual meeting where clinicians come together to reflect on and learn from mistakes.

“However, we must also recognise that these findings reflect a system that is overburdened and under-resourced.

“We face a 30% shortfall of clinical radiologists, projected to rise to 40% by 2028.

“As the Ombudsman points out, inadequate digital infrastructure is a patient safety issue.

“We urge the government to act on these findings and invest in the capacity and infrastructure necessary to support NHS staff to give every patient the care they deserve.”

Government figures, published on 11 July 2024, revealed that the UK continues to have lowest number of MRI units, CT and PET scanners per million population amongst comparator countries.

The Labour manifesto promised to introduce a ‘Fit for the Future’ fund to double the number of CT and MRI scanners and bring in AI-enabled scanners.