Patients being harmed due to 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 publishing a report four years ago 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 more than 40 cases in which similar failings were found.

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.

Rebecca Hilsenrath KC, Parliamentary and Health Service Ombudsman, said:

“Each of the cases we have investigated and upheld represent a real person whose life has been impacted by failings in care. They are also all instances where the organisations involved failed to identify that anything had gone wrong.

“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.”

In one of the investigations, PHSO found that doctors at Wexham Park Hospital repeatedly failed to diagnose a grandfather’s cancer which delayed his treatment and left him in prolonged pain.

He was diagnosed with bowel cancer on his fifth visit to A&E within three months, by which time he was in extensive pain. The 82-year-old took his own life, leaving a note saying he could no longer deal with the pain.

PHSO found that clinicians failed to report a small bowel lesion from a scan in August 2021. This failure led to a six-week delay in diagnosing the obstruction and in carrying out surgery, and prolonged the pain the patient was enduring.

The Ombudsman concluded that the failings in care were probably contributory factors to the patient’s decision to end his life.

PHSO recommended that the Trust pay the man’s daughter £4,000, apologise, and develop an action plan to address the failings identified. The Trust has agreed to comply.

The man’s daughter said:

“I really tried to get the doctors to listen. I had a feeling something was wrong and I pleaded numerous times for them to keep him in the hospital but they just kept discharging him and not doing anything to help him.

“My dad was clearly thin and clearly vulnerable and they didn’t care. Doctors should be prioritising vulnerable people because the outcome can be so much worse for them, and they should be held accountable if they don’t. I feel that my dad killed himself because of failures in his care. I have no father now and I have to live with that. I am completely on my own now.”

In another investigation, PHSO found that a cancerous tumour was misidentified as benign by Kings College London Hospital despite repeated scans showing it was malignant.

The tumour was identified as a glioblastoma, a very aggressive type of cancerous tumour found in the brain, by a hospital in Tenerife after the man, who was 54, became unwell while on holiday there.

After returning home to Gillingham, he attended a hospital where staff carried out further scans that also identified the tumour and referred him to Kings College London Hospital, a specialist referral centre for brain cancer.

Kings College staff reviewed the scans and downgraded the diagnosis, saying the tumour was non-cancerous. The man’s care was consequently deemed non-urgent during the pandemic and he was not offered chemotherapy or radiotherapy.

His cancer was missed again during further tests. During an operation in October 2020 to remove the tumour that doctors believed to be benign, he suffered a massive bleed which led to severe respiratory failure, brain damage, kidney failure, deep vein thrombosis and lung clots. He died in hospital four weeks later.

PHSO found that if the cancer had been correctly identified this surgery would have been offered nine months earlier. If recovery went well, surgery would have been followed by chemotherapy and radiotherapy.

While this type of cancer has a poor survival rate, the Ombudsman found that his life might have been extended for a few more months had the diagnosis been made earlier.

PHSO recommended the Trust pay the family £3,500. They also recommended the Trust apologise and create an action plan to prevent this from happening again. The Trust has agreed to comply.

The man’s brother, 56, from Tunbridge Wells, said:

“When my brother collapsed in Tenerife, the hospital immediately identified the tumour for what it was and even offered to remove it. But my brother wanted to come home, he thought the best place for him to have the treatment was in the NHS.

“The tumour growing should have been a warning sign and I cannot understand why they kept insisting it wasn’t cancerous. They should have assumed the worst, not hoped for the best. It felt like they were taking a blasé approach to his symptoms.

“I came to the Ombudsman because something had gone wrong with my brother’s care and I wanted to know that at least a learning process could come out of it. I wanted Kings College to acknowledge their mistakes so that I can stop picking at the scab of trying to understand what happened to him and remember my brother as he was when he was alive.”