Patients dying unnecessarily because of NHS scan failures, Health Ombudsman says
In cases referred to the PHSO, the NHS trusts involved have often failed to acknowledge or identify their mistakes.
Patients are dying unnecessarily and others are facing unacceptable delays because of repeated failings in the way NHS scans are read, the Health Ombudsman has said.
Despite a report four years ago into mistakes in the reading and reporting of images, the Parliamentary and Health Service Ombudsman (PHSO) said it has since upheld or partly upheld more than 40 cases in which similar failings were found.
A new review has found the most common issues are doctors failing to identify abnormalities such as tumours, scans not being carried out or being delayed, and results not being properly followed up.
In one case, a 10-month delay in cancer being diagnosed “significantly” harmed the person’s chance of survival, while another patient had serious pelvic sepsis missed, which led to an avoidable death.
Another patient had to undergo an avoidable operation after an ankle fracture was missed by NHS staff.
In cases referred to the PHSO, the NHS trusts involved have often failed to acknowledge or identify their mistakes.
PHSO for England, Rebecca Hilsenrath KC, said: “Each of the cases we have investigated and upheld represent 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.
“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.
“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.”
In one of the investigations, PHSO found that doctors at Wexham Park Hospital in Slough repeatedly failed to diagnose a grandfather’s cancer, leaving him in intolerable 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 man, 82, took his own life, leaving a note saying he could no longer deal with the pain.
An investigation by PHSO found medics failed to report a small bowel lesion from a scan in August 2021.
This failure led to a six-week delay in diagnosing the bowel obstruction and in carrying out surgery, leaving the patient in extensive pain.
The Ombudsman concluded that the failings in care were probably contributory factors to the patient’s decision to end his life.
PHSO recommended the trust pay the man’s daughter £4,000, apologise, and develop an action plan to address the failings identified. The trust has agreed to comply.
The man’s daughter said: “I really tried to get the doctors to listen.
“I had a feeling something was wrong and I pleaded numerous times for them to keep him in the hospital but they just kept discharging him and not doing anything to help him.
“My dad was clearly thin and clearly vulnerable and they didn’t care.
“Doctors should be prioritising vulnerable people because the outcome can be so much worse for them, and they should be held accountable if they don’t.
“I feel that my dad killed himself because of failures in his care. I have no father now and I have to live with that. I am completely on my own now.”
In another investigation, PHSO found a cancer tumour was misidentified as benign by King’s College London Hospital, despite repeated scans showing it was malignant.
It was only when the man, 54, was on holiday in Tenerife and fell ill that the tumour was identified as a glioblastoma, an aggressive type of brain cancer.
After returning home to Gillingham, Kent, he went to hospital where scans showed the tumour and he was referred to King’s, which is a specialist referral centre for brain cancer.
Staff at King’s reviewed the scans and “downgraded the diagnosis”, the PHSO said, instead marking the tumour as non-cancerous.
The man’s care was also deemed non-urgent during the pandemic and he was not offered chemotherapy or radiotherapy.
Further tests also missed his cancer. During an operation in October 2020 to remove the tumour that doctors believed to be benign, he suffered a massive bleed which led to severe respiratory failure, brain damage, kidney failure, deep vein thrombosis and lung clots.
He died in hospital four weeks later.
PHSO found that if the cancer had been correctly identified, this surgery would have been offered nine months earlier, followed by chemotherapy and radiotherapy.
While glioblastoma has a poor survival rate, PHSO said his life may have been extended by months so he could spend more time with his family.
The trust was told to pay £3,500, apologise and create an action plan to prevent this from happening again. The trust has agreed to comply.
The man’s brother, 56, from Tunbridge Wells, Kent, said: “When my brother collapsed in Tenerife, the hospital immediately identified the tumour for what it was and even offered to remove it.
“But my brother wanted to come home, he thought the best place for him to have the treatment was in the NHS.
“The tumour growing should have been a warning sign and I cannot understand why they kept insisting it wasn’t cancerous.
“They should have assumed the worst, not hoped for the best. It felt like they were taking a blase approach to his symptoms.”
An NHS spokesperson said: “NHS staff work extremely hard to keep patients safe and thanks to the continued expansion of community diagnostic centres, the NHS delivered a record number of tests and checks in 2024, a fifth more than pre-pandemic, but we know there is more to do to improve the recognition and response of serious health issues.
“Patient safety incidents like those highlighted in this report are responded to in line with the Patient Safety Incident Response Framework and the NHS will continue to provide targeted improvement measures for local areas through intensive support, the use of straight to test measures and performance improvement programmes tailored to different areas of diagnostics.”
Dr Katharine Halliday, president of the Royal College of Radiologists, added: “We were deeply saddened to read of these cases.
“The Ombudsman highlights some devastating failures in the NHS, and we must collectively learn from these experiences to drive meaningful change.”
