An x-ray that wasn’t followed up resulted in a “missed opportunity” to uncover a patient’s fatal cancer diagnosis, a new report has revealed.
he woman attended the emergency department (ED) of Daisy Hill Hospital in Newry, Co Down, in April 2018 with chest pains.
An x-ray found a “subtle abnormality” on her one of her lungs and a follow-up x-ray was requested within six to eight weeks.
However, no follow-up x-ray took place and a year later, after returning to the hospital with chest pains, another x-ray identified a “mass” on the woman’s lung.
She was diagnosed with lung cancer a couple of weeks later and died from the disease in June 2020.
The Southern Health and Social Care Trust (SHSCT), which manages Daisy Hill Hospital, has apologised to the woman’s family for the “failings” in the care she received.
The woman’s daughter had complained to the Northern Ireland Public Service Ombudsman (NIPSO), Margaret Kelly, about the manner in which her mother had been treated.
The ombudsman looks into complaints about health bodies and other public sector organisations.
After the initial complaint was made to NIPSO, the trust agreed to carry out a serious adverse incident (SAI) investigation into the case. An SAI is defined as any event or circumstance that led or could have led to unintended or unexpected harm, loss or damage.
However, the woman’s daughter said the SAI report failed to clearly outline what happened and did not put forward adequate recommendations to ensure something similar could not happen again. As a result, another complaint was lodged with the ombudsman who conducted a separate investigation. The investigation report found “several failings” on the trust’s part in relation to how the deceased woman and her family were treated.
During her investigation, Ms Kelly said SHSCT admitted its process for the sign-off of radiology reports was “not fit for purpose”. Radiology uses imagining technology such as x-rays to diagnose and treat diseases.
The trust said the paper-based system used to share x-ray details was “not incapable of error” and added there was no ability to check that relevant staff “progressed the recommended actions noted on each radiology report”.
Ms Kelly said the “errors” in how the woman, who was not identified in the NIPSO report, was treated occurred after the radiology department issued the x-ray report, and not during or immediately after the woman’s attendance in the hospital’s emergency department.
“I note the SAI report identified that the x-ray report issued on April 22, 2018, stated a follow-up x-ray should take place in six to eight weeks’ time,” she said.
“The SAI report also identified that this follow-up x-ray was not requested, and that as a result there was a missed opportunity for the patient to have received an earlier diagnosis. The trust further identified that this diagnosis resulted in the patient’s death.
“The SAI report identified that the x-ray report had not been marked as urgent by the radiology department, which meant that its findings were not highlighted to the ED team.”
The ombudsman said the trust’s investigation was unable to determine where the problem with the x-ray had occurred, stating it was “unable to determine whether the report was mislaid on its route to the ED, or during its time in the ED, or whether it was misfiled on arrival at the ED, or whether it was correctly filed, but not acted upon”.
Ms Kelly said the SAI report did not consider the effect of the terminal diagnosis on the patient or her family “in an empathetic manner”.
“The SAI report states that the x-ray report was not reviewed, and this resulted in the patient being denied the opportunity for earlier treatment.
“The report goes on to state that had the ED consultant reviewed the x-ray report, either a follow-up x-ray would have taken place or a red-flag referral would have been made to the respiratory team for an urgent CT scan.”
Ms Kelly’s report said the trust should apologise to the woman’s family and she put forward a series of recommendations for the trust to implement.
Among the recommendations put forward in the report was a requirement for the trust to review how x-ray reports are handled, including the implantation of a new digital sign-off system and the introduction of a sign-off sheet in the emergency department for staff delivering physical reports.
A spokesperson for the trust told the Sunday Independent a letter of apology had been sent to the deceased woman’s family.
“Failings identified in the report have been shared with relevant staff for learning and improvement,” the spokesperson added.
“The trust is taking appropriate action in relation to the recommendations made by the ombudsman in the NIPSO investigation report.”