• NHSX and Royal College of Radiologists reveal work on radiology failures
  • “Systemic failings” meant a woman did not find out about suspected lung cancer until three months after tests 
  • Organisations urged to create method of digitally notifying patients of significant radiology findings

National officials are working with radiologists on systems to digitally warn patients of diagnostic test results, after the NHS failed to inform a woman of signs of her lung cancer.

Recently published statements from the organisations sent safety recommendations off the back of the Healthcare Safety Investigation Branch’s investigation into the incident, which happened in summer 2017, said they are exploring creating a method of digitally notifying patients of significant radiology results.

NHSX’s response to the HSIB recommendations said “discovery” work has been carried out to “establish potential solutions and guidance that NHSX can provide to improve digital practice and ultimately patient safety”.

The statement, published this month, said: “We acknowledge and agree with the report’s recommendation that a method should be developed to digitally notify patients of unexpected significant radiological findings after an agreed timeframe…

“We are already aware of local areas using patient facing portals to provide results to patients and our national work with the GP connect programme is looking specifically at capabilities to support tasking and alerting to GPs.”

When asked by HSJ about the next steps, NHSX said: “We intend to continue this work in the next financial year as we recruit more staff.”

Meanwhile, the Royal College of Radiologists has assessed which conditions should always trigger an alert when discovered, following recommendations from HSIB.

The HSIB report, published in July last year, stated patient harm as a result of failures to follow up radiological findings was a “long and persistent problem”.

The report focussed on the case of a 76-year-old woman whose cancer was unexpectedly picked up when she was admitted into hospital for tests after having a heart attack. She had a chest X-ray, which was initially assessed as normal by a junior doctor.

A radiologist spotted signs of lung cancer while completing an X-ray report around 12 days after the first admission. An email and letter were sent to the hospital’s cardiac team, and the letter copied to the woman’s GP.

However, the letters were never received and the cardiac team failed to act on the email, according to the HSIB report. The report stated: “It is not clear whether the letter was printed or lost at some later point.”

The results were only picked up again three months later when the patient visited her GP complaining of chest pain, weight loss and a persistent cough. The GP then accessed the woman’s test results and found the X-ray report.

Following further tests, the woman was diagnosed with lung cancer. She died two months later.