Ongoing failure to properly review chest x-rays leads to missed cancer diagnosis
I was very concerned to hear on the news that the care quality commission found during an inspection at the Queen Alexandra Hospital in Portsmouth in July 2017, that a backlog of 23,000 chest and abdominal x-rays has not been formally reviewed by a qualified radiologist or suitably trained technician. It has been reported that the trust has identified three patients so far, who have suffered harm as a result of lung cancer not being diagnosed or an unreported x-rays.
Not only is this extremely concerning for any patients who may have had reason to attend the radiology or outpatient department at QAH over the last 12 months, but it is also extremely disappointing that lessons have not been learned from earlier incidents.
I act for a gentleman who attended the A&E department at QAH in May 2014 following a fall from a height. A chest x-ray was performed as part of those investigations and was reported by a junior A&E doctor as showing no abnormalities. After being checked over, my client was discharged home.
Towards the end of 2014, the gentleman in question began suffering from fatigue and a long-standing cough. His health deteriorated and he was eventually referred for a further chest x-ray in May 2015. This showed a tumour in his lung. When the radiologist reviewed the x-ray taken a year previously, it was apparent that the tumour had been visible on that earlier x-ray but had been missed. Because of the delay in diagnosis and growth of the tumour, my client’s treatment options were far more limited by the time of diagnosis.
The hospital instigated an internal investigation which concluded that the tumour could and should have been diagnosed in May 2014, had it been reviewed by a radiologist. The investigation reported though that because the x-ray had only been reviewed by a junior doctor in the A&E department who was not trained to formally report on chest x-rays and because the x-ray was taken to rule out a traumatic injury at the time, it was understandable that the tumour had been missed.
The Chief of Service for the Emergency Clinical Technical Support Centre was involved in the internal investigation and stated that in his opinion all Emergency Department images should receive formal radiology reports in order to pick up any abnormalities missed by emergency department doctors. However the NHS Trust reported at that time that there was insufficient reporting capacity in the Imaging department to routinely report all plain film Emergency Department and Medical Assessment Unit images, which at the time amounted to approximately 80 to 95 images per day. This policy had apparently been extensively discussed by the executive management team and Trust governance committee and ratified as Trust policy, with the Trust accepting the risk that flows from such a policy.
However I would suggest that the decision as to what is an acceptable level of risk is one which properly lies with the patient, given the devastating impact that a missed diagnosis can have on their lives and future treatment options.
It would seem as though, despite being aware of these problems associated with the level of training provided to junior emergency department doctors and reporting capacity within the imaging department as long ago as 2015, Portsmouth Hospitals NHS Trust has still not taken the necessary steps to ensure that all patients attending the hospital have their x-rays reviewed by somebody who is trained and competent to accurately report on them. This can only lead to more individuals suffering as a result of a delay in diagnosis and effective treatment and ultimately, an increase in cost to the Trust in having to treat patients whose condition is more advanced than it would otherwise have been and resulting clinical negligence compensation claims.
Whilst I was pleased to note that Portsmouth Hospitals NHS Trust states that it has now tackled approximately half of the backlog of x-rays identified in July 2017, it is difficult to see why the situation was able to continue for so long, given the catastrophic impact that a delay in diagnosis can have on patients.
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