England’s Health ombudsman has warned that a failure to identify problems on scans leads to delays in diagnosis, unnecessary operations and avoidable death. 

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.

Following 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.

“Each of the cases we have investigated and upheld represents 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,” said Rebecca Hilsenrath, parliamentary and health service ombudsman.

“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,” she added. 

Failures have impact

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 ten-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.

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. 

“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,” said Hilsenrath. 

The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made.