Investigation into communication of unexpected scan findings underlines “ongoing, widespread potential for patient harm”

Thursday 18 July 2019

The Royal College of Radiologists (RCR) has strongly endorsed a new report into how serious unexpected findings on patient scans are handled by hospital staff.  

During 2018, the Healthcare Safety Investigation Branch (HSIB) conducted an England-wide investigation into the issue, following the death of patient whose lung cancer went untreated after doctors failed to act on her X-ray results. The 76-year-old patient was originally scanned following a suspected heart attack, and although her cancer was detected by a radiologist, the diagnosis was passed between various clinical teams but did not reach the patient or her GP.

The HSIB investigation uncovered widespread variation in how unexpected radiological findings are flagged, communicated and acted on by clinicians, highlighting how efficient communication is often put at risk by complicated processes and poor hospital IT.

The agency has now tasked the RCR, NHS leaders and the Care Quality Commission with a series of recommendations to ensure unexpected scan findings are flagged and followed-up to national standards, and that, in future, patients will be digitally notified of any serious unexpected imaging results.    

Professor Mark Callaway, one of the advisors to the HSIB investigation and the RCR’s Medical Director of Professional Practice for Clinical Radiology, said:

“Today’s HSIB “Failures in communication” report details a comprehensive, important investigation which shines a telling light on fundamental issues around patient follow-up and alerts within the NHS in England. These overarching issues are mainly as a result of widespread local variation in IT and administrative capability and alert procedures, as well as patient handover procedures, all of which are crucial in ensuring radiological findings are flagged, acknowledged and acted on. 

“While the HSIB investigation was sparked by a single, extremely tragic missed case of lung cancer, it revisits long-standing systemic issues around the follow-up of hospital scans and reveals an ongoing, widespread potential for patient harm.    

“Sadly, the investigation team’s discoveries of delayed imaging results, variable or non-existent alert and acknowledgement systems, complicated patient follow-up procedures and varied IT and administrative support, are neither new nor surprising. As the HSIB points out, these issues – and the dangers they pose – have been flagged by multiple bulletins and Royal College clinical guidance documents over the past decade1.

“The investigators also emphasise the safety risks posed by delays in radiology reporting, frankly stating that the operational ideal of ‘hot reporting’ of A&E X-rays and scans, while desirable, is simply not currently achievable within the NHS, as a result of the ongoing national shortage of radiologists.  

“The RCR was a central advisor to the HSIB investigation and we are extremely pleased that the agency has issued us – alongside NHSX, NHS England/Improvement (NHSE/I) and the hospital regulator – with practical undertakings to improve the management of unexpected radiological findings across England. 

“Much of the onus remains on hospital trusts to ensure they have robust alerts systems, escalation procedures and supporting IT to ensure radiological findings are acted upon. We will continue to provide imaging teams with professional support and guidance on these issues, and hope central Government and NHSE/I will be able to support providers with much-needed capital investment to improve IT, so that the necessary electronic alert systems can actually be implemented in our hospitals and GP practices.       

“Meanwhile, we look forward to getting to work on the report’s recommendations – that we produce a national alerts framework for trusts to incorporate into their local IT, and help NHSX develop a digital notification system for patients. We will be publishing a formal response this autumn, with the aim of finalising a national alerts and coding framework for use in English hospitals within the next 12-18 months.”  

1. Patient safety concerns were originally raised in a National Patient Safety Agency Safer Practice Notice in 2007. The RCR has published various UK-wide documents about alerts systems and the communication of scan results, including our most recent guidance, “Standards for the communication of radiological reports and fail-safe alert notifications”, published in 2016.

Notes to editors
The full HSIB recommendations are:

1. The Royal College of Radiologists (RCR), working with the Society and College of Radiographers and other relevant specialties through the Academy of Royal Medical Colleges, develops:

  • principles upon which findings should be reported as ‘unexpected significant’, ‘critical’ and ‘urgent’,
  • a simplified national framework for the coding of alerts
  • a list of conditions for which an alert should always be triggered, where appropriate and feasible to do so.

It has also been suggested that the RCR consider the potential for standardisation in radiology reporting, in reference to the advent of artificial intelligence in clinical practice.  

2. NHS England and NHS Improvement’s patient safety team takes steps to ensure providers are aware of the safety recommendations in this report and act to implement the key findings regarding risk controls such as a monitored acknowledgement system for critical, urgent and unexpected significant findings.

3. NHSX develops a method of digitally notifying patients of results. This should be used to inform patients of unexpected significant radiological findings after an agreed timeframe. It should be developed in conjunction with the Royal College of Radiologists. The notification system should be tested and evaluated. 

4. The Care Quality Commission amend all appropriate core service frameworks to include risk controls identified in this report to mitigate the risk of significant abnormal findings not being followed up.