RADIOLOGY
Calls for improvement to imaging services
The Parliamentary and Health Service Ombudsman (PHSO) has written to the Government urging it to prioritise improvements to NHS imaging services as part of the health sector’s recovery from the COVID-19 pandemic.
The Parliamentary and Health Service Ombudsman (PHSO) report, Unlocking Solutions in Imaging,1
shows recurrent failings
in the way X-rays and scans are reported on and followed up across NHS services. PHSO’s casework shows the devastating impact these failings have had on patients and their families. In several cases, signs of cancer in X-rays and scans were not reported, which led to delayed diagnoses and poorer outcomes for the patients. In one case, an 18-month delay in diagnosing pancreatic cancer meant a patient missed out on getting earlier treatment that could have prolonged their life. In another case, a patient was not told that their cancer was terminal until it was too late for them to get their affairs in order and see their son before they died. Another common failing was inefficient handovers between departments and services. Investigations also found that Trusts did not learn from previous errors related to imaging, which meant they repeated the mistakes. Among the key findings included failure to follow national guidelines, failure to act on important unexpected findings, delays in reporting imaging findings and failures to learn from past mistakes. The report highlighted the need to implement the recommendations from previous work relating to imaging, including recommendations made by the Healthcare Safety Investigation Branch (HSIB)
following its national investigation,2
the
Care Quality Commission’s national review of radiology reporting within the NHS3 and the Independent Review of Diagnostic Services for NHS England and Improvement (NHSEI).4
It also added that:
1) Digital infrastructure must now be treated as a patient safety issue. The Ombudsman called for the Department of Health and Social Care (DHSC) and NHSEI to work with NHSX and NHS Digital to
In one case, an 18-month delay in diagnosing pancreatic cancer meant a patient missed out on getting earlier treatment that could have prolonged their life. In another case, a patient was not told that their cancer was terminal until it was too late for them to get their affairs in order and see their son before they died.
SEPTEMBER 2021
prioritise improvements in digital reporting capabilities across the imaging system. 2) DHSC and NHSEI should ensure there is national guidance on the roles and responsibilities of clinicians, and expected timeframes, at each stage of the imaging journey.
3) NHS-funded providers should ensure staff working in radiology services have sufficient allocated time in their job plans for meaningful learning and reflection. This should include identifying and sharing the learning from discrepancies, and peer review of radiological reports.
4) Clinical directors and senior managers should triangulate the learning from across their departments on a regular basis. This should be no less than four times a year to identify systemic or recurring issues. (This should include the learning from Radiology Events and Learning Meetings [REALM], complaints, claims, serious untoward events, patient safety issues, Freedom to Speak Up Guardian data and candour learning.)
WWW.CLINICALSERVICESJOURNAL.COM l 59
▲
©Picture Partners Holland
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88
