The Operating Theatre Journal

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 letter highlights findings from the Ombudsman’s report that 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.

In his report, Ombudsman Rob Behrens stresses that failings related to imaging are found across the NHS, in both primary and secondary care services, and not solely in imaging departments. He calls on the Government to commit to a system-wide programme of improvements for more effective and timely management of X-rays and scans.

Ombudsman Rob Behrens, said:

‘X-ray and scan results are key to diagnosis and treatment for many people. Yet the failings outlined in this report show that without a concerted effort to improve imaging, patient safety continues to be at risk.

‘Now, as the NHS recovers from the devastating impact of the pandemic, we have a vital opportunity to learn from the failings and embed system-wide changes to improve imaging in the health service.

‘The evidence-led recommendations I have set out should be implemented swiftly, with collaboration across government and the health sector to strengthen the NHS’s recovery.’

For many of the 5 million people currently waiting for hospital treatment, imaging will be a crucial part of their care. Effective diagnosis will be an essential first step in tackling the backlog caused by the pandemic, further highlighting the need for rapid action on improvements.

Peter Walsh from the patient safety charity Action against Medical Accidents, said:

‘We very much welcome this report, which underlines the urgency of improving radiology services across the board, including recognition, reporting and acting on imaging results.

‘We see in our own work how vital diagnostic services are, and the awful effect on people’s lives when they go wrong. There have now been a raft of reports and recommendations about improving radiology services.

‘This is a major patient safety issue, and we need to see the various recommendations implemented as a matter of urgency.’