- Patients came to “severe harm” as a result of care failings at St George’s University Hospitals FT
- Report obtained by HSJ shows issues in communication and processes
- Trust says situation has improved with new IT system
Radiology failings at a teaching hospital led to eight patients coming to severe harm, with three dying, a hospital trust has admitted.
A report into issues at St George’s University Hospitals Foundation Trust identified multiple problems, including staff missing cancers, improperly reported results and diagnoses being sent to unmonitored inboxes.
The document released under the Freedom of Information Act outlined the serious incidents and a spokeswoman admitted that of the three patients who died, “on the balance of probabilities, it is likely the delayed diagnoses were a contributing factor.”
It added: “We have rightly apologised to the patients and relatives of all those included in the report for providing a standard of care that fell short of high standards we would expect, and lessons have been learned as a result.”
The south London secondary and tertiary provider admitted that, in four of the eight incidents, there were “incidental findings of malignancy that were not escalated initially by clinicians”.
The report added: “It was apparent that fax alerts or emails to individual clinicians would not always provide a sufficient[ly] systematic approach.”
The NHS National Reporting and Learning Service defines “severe harm” as “permanent harm”.
The report to a private board sub-committee said that since the initial findings were delivered and changes were introduced, “there [have been] no incidents where an unexpected finding of a malignancy was not escalated as described above”.
The trust has now introduced “clinic outcome forms with the aim to capture actions from any consultation in a reliable way”.
St George’s has faced significant problems with poor recording of patient data and waiting list management leading to patient harm over recent years.
In April, an assessment from the trust put the number of people coming to severe harm as a result of serious failings in its patient records system at 15.
The review disclosed under the FOI Act said the trust had now changed the way radiology reports worked and introduced “reliable systems in high volume areas such as [the] emergency department”.
In a statement, the trust said: “It is important to stress that the imaging in the four cases [where malignancies were not escalated] was performed for other indications (eg an urgent scan for trauma, or to exclude other pathologies), and not to look specifically for cancer. As stated on page 5 of the report, the changes were subtle and not always identified even on peer review.”
The “thematic analysis” (attached), sent to board members in February this year, examined 10 serious incident reports from 2017 and 2018, which were selected by Wandsworth Clinical Commissioning Group.
Two other patients identified in this review suffered severe harm but “this was found not to have resulted from failings in care”.
- PDF, Size 0.27 mb
- PDF, Size 1.41 mb