- HSIB interim bulletin on radiology reporting raises concern over national systemic risks to safety
- Investigation follows death of 76 year old discharged 12 days before X-ray revealed lung cancer
- Royal College of Radiologists warns against clinicians relying on exception reporting as the norm
Patients with undiagnosed cancer are being discharged from hospital before crucial radiology scans are completed because of demands to free up hospital beds, it has emerged.
According to the Healthcare Safety Investigation Branch, demands on hospitals to reduce the length of stay for inpatients means some are being sent home days and weeks before requested scans are reported back.
In other cases poor and variable communication and IT systems mean vital radiology scans such as X-rays, CTs and MRI scans are not being picked up and acted on.
The investigatory body, set up in 2017 to improve systemic learning from incidents, warned there was also ambiguity about who was responsible for acting on reports when patients were being cared for by multiple specialist teams.
The HSIB investigation was prompted by the death of a 76 year old woman who died from lung cancer which was spotted in an X-ray requested by accident and emergency staff but not reported for 12 days – by which time the patient had been discharged.
She had been diagnosed as having a heart attack and spent six days on a cardiac ward.
A hard copy of the X-ray report and an email was sent to the cardiology team and her GP but HSIB said the letters were not received and the email not acted on.
The patient attended her GP three months later with back pain, weight loss, a cough and chest pain. The GP then saw the X-ray in the IT system showing possible lung cancer. The diagnosis was confirmed but the patient died a few months later.
According to HSIB, during 2018 there were 41 incidents of delayed diagnosis of lung cancer where radiological findings were made but no action taken. HSIB said the now defunct Patient Safety Agency had highlighted similar concerns more than 10 years ago.
In an interim bulletin ahead of a final report, HSIB said: “Pressures on the healthcare system add to the challenge of effective and timely communication and follow-up of radiological results. These include pressure to reduce in-patient length of stay, which increases the risk of tests not being reported before a patient is discharged.”
It added: “There is substantial human cost when these incidents occur, and these events undermine patient confidence and trust in healthcare services. They also incur a financial burden and can seriously damage a hospital’s reputation.
“Recommendations and professional standards, published to ensure significant radiological results are seen and acted upon, have so far not resolved this patient safety risk.”
Almost 23m X-rays, ultrasound, CT and MRI scans were carried out in 2016-17 amid a significant workforce crisis in radiology with trusts reporting a 14 per cent vacancy rate.
Sam Chakraverty, a consultant radiologist and patient safety advisor to the Royal College of Radiologists, said HSIB had identified a systemic risk to patients.
“As a patient having an X-ray you make several assumptions. One is that there will be a report, another is it will be correct, a third is that it will be read, and fourth that it will be actioned. Actually, none of those are true for a variety of reasons,” he said.
“Most radiologists will be aware of similar incidents happening in their own hospital. This is quite common, and many go under the radar.
“There is a workforce issue in radiology that means we end up with delayed reports and that feeds into a system where clinicians are quite mobile, and patients go through the system much quicker and the consequence of all of that is there is much more room for error than there might have been 20 years ago.”
He added that while trusts had implemented new “fail-safe” reporting systems for significant unexpected findings, the way it was done varied between hospitals.
“It has had some very unintended consequences, such as in areas where clinicians are very busy they are tending only to look at reports where fail-safe alerts are issued.
“Fail-safe reporting is a good thing to do but it should be the exception. As soon as it becomes the norm then lots of reports just won’t be read and some of those will have significant pathology on them.”
HSIB said its full investigation would examine the human factors and IT systems which impact on communication and follow-up of test results as well as the variation in practice on how unexpected significant findings are communicated.
It will also look at learning from organisations that have created systems to improve communication.
Safety concerns about radiology services have emerged as a key safety concern after the Care Quality Commission found wide variation in radiology reporting nationally.
The regulator’s report followed patients dying at Queen Alexandra Hospital in Portsmouth following missed cancers, and backlogs of thousands of unreported images at Worcester Royal Hospital and Kettering General Hospital.