A report published by the Care Quality Commission on 1 December 2017 revealed that The Queen Alexandra Hospital has been made the subject of urgent action by the CQC in light of failings in the way chest and abdomen x-rays were reviewed between 1 April 2016 and 31 March 2017.
During this period the CQC has uncovered that 26,345 chest x-rays and 2167 abdomen x-rays, referred via the Emergency Dept, did not receive a formal radiological report. The x-rays were instead interpreted by the referring doctor, where the accepted practice is that reporting on x-rays should be carried out by a radiologist who is trained to spot abnormalities that would not necessarily be apparent to a medical professional from another discipline.
The CQC was told of three serious incidents at the QA which were caused by the failure to properly interpret chest x-rays. Tellingly, the incidents all pre-date the period being investigated by the CQC. In the first case a patient attended in 2014, and the x-ray was interpreted by a junior doctor who at the time recorded no abnormality. One year later, the patient was referred by his GP for a second chest x-ray. This time, the x-ray was reported on by a radiologist who reported evidence of lung cancer, which was felt to have been present on the previous chest x-ray. The second case was similar – the patient having attended for a chest x-ray in late 2015. Ten months later the patient was re-x-rayed and found to have advanced lung cancer. The third case, which involved a lengthy delay in a diagnosis of lung cancer, was still under investigation at the time of the CQC’s report being published, but a provisional cause was identified as a delay in the chest x-ray being reviewed by the referring clinician, or radiologist.
In light of the failings, the CQC has taken urgent action under Section 31 of the Health and Social Care Act which requires the QA to meet the following fundamental standards :
- The Hospital must resolve the backlog of radiology reporting, using appropriately trained members of staff, and must assess the impact of harm to patients and must apply their Duty of Candour to any patient adversely affected;
- The Hospital must ensure they put in place robust processes to ensure any images taken are reported and risk assessed in line with Trust policy;
- The Hospital must submit their plan on how to address the backlog
- From 6/9/2017 the Hospital must produce weekly reports to the CQC as to the number of images remaining in the backlog and the current trajectory date of when the backlog will be cleared.
David Hawkins, a Clinical Negligence lawyer from Verisona Law said : “It is clear from reading the CQC’s findings that the problem was, at least in part, due to a lack of capacity in reporting radiology. What is of real concern however is that the Hospital’s actions went against the accepted practice of having trained radiologists interpreting x-rays which has led to extremely serious outcomes for the three patients that we know of in the report. There may well be many more people affected by late or misdiagnosis of serious conditions which were not picked up following x-rays at the QA."
If anybody believes that they, or their loved ones, may have been affected by the issues highlighted by the CQC’s report, our team of experienced medical negligence lawyers will be happy to provide you with help and advice.