RCR welcomes Ombudsman’s calls for improvements to NHS radiology services

Thursday 8 July 2021

The RCR has welcomed calls by the Parliamentary and Health Service Ombudsman (PHSO) for the Government and hospital trusts to prioritise improvements to NHS radiology IT systems and alerts processes. 

The Ombudsman has written directly to the Government about the issue, highlighting findings from its new insight report, released today. 

The report, Unlocking Solutions in Imaging, reviews and collates a range of patient stories involving missed or delayed diagnoses of significant findings following an X-ray or scan, and documents recurrent themes of varied or poor escalation procedures and communication between hospital teams. 

It builds on a string of NHS imaging reviews and recommendations made in recent years – including reports by the Care Quality Commission, the Healthcare Safety Investigation Branch (HSIB) and NHS England’s commissioned review into the post-pandemic recovery of diagnostic services.

The PHSO report calls for the recommendations of those previous investigations to be urgently progressed and clearly managed by NHS England and Improvement (NHSEI).

Other systems-level recommendations for NHSEI and the Department of Health and Social Care include prioritising digital imaging system improvements as a key patient safety concern and ensuring there is national guidance on radiology reporting roles and procedures.

The PHSO also calls on individual NHS providers to ensure radiology staff have allocated time for reflective learning, that hospital radiology leads regularly collate and share learnings and intelligence of imaging issues, and that the RCR ensures its guidance on the reporting of unexpected significant findings is clear and continually updated. 

As well as producing routine guidance and learning materials on radiology reporting best practice, the RCR is also actively involved in advancing recommendations made in the previous service reports highlighted by the PHSO. Efforts include leading a sector-wide working group in the process of creating radiology alerts standards, as requested by the 2019 HSIB report into unexpected imaging findings, and ongoing collaboration as part of NHSEI’s national imaging board.     

Commenting on the PHSO report and recommendations, RCR President Dr Jeanette Dickson said:

“We highly commend the Ombudsman for its report. We advised the investigation team and wholly support its recommendations – some of which are already underway – and will continue to push for them to be realised. 

“Themes of delayed, variable or non-existent follow-up of radiology results and missed learning will be rightly shocking to patients. Sadly, they are no surprise to us, over-stretched hospital teams, the NHS or Government, and these themes have been repeatedly highlighted in various sector reviews over the past four years. They will also be familiar to NHS imaging teams across the UK, not just in England.  

“We are pleased the PHSO has called for urgent action on those previous investigations and we have been working with NHSEI and partner organisations to progress them. The intrinsic complexity of radiology across systems and patient pathways – plus a hiatus due to COVID-19 – has slowed down work, but we need pressure back on to improve NHS imaging. We hope to see real improvements by the time DHSC/NHSEI provide an official update in spring 2022.  

“The PHSO report highlights tragic cases whereby significant unexpected imaging findings were missed or not escalated promptly. The RCR is extremely clear, across all our guidance and training, that reporters must flag such discoveries if they detect them. 

“Honest mistakes can and do happen in medicine. Imaging reporters do sometimes miss findings due to perceptual and cognitive errors, in addition to a variety of intrinsic and extrinsic factors. The RCR and its members work hard to ensure errors are minimised and patients are kept safe by publishing national guidance and providing support for learning and reflection. We will continue to emphasise and incorporate this in all future clinical guidance and guidance reviews.

“The Ombudsman’s call for NHS digital shortcomings to be addressed as an urgent patient safety matter is both bold and pivotal. The COVID-19 response has demonstrated the NHS can make rapid digital improvements, such as rolling out remote and networked scan reporting. Innovations in imaging IT must continue as the health service recovers, and trusts must be centrally supported to allocate the staff time and capital investment needed to upgrade IT and alert systems. 

“Hospital imaging teams are under more pressure than ever, battling through covid backlogs on top of spiralling demand for radiology scans and procedures, and it is crucial that any system and local-level efficiencies that can happen, do. Staff desperately need breathing space to implement systems change, but this will only take us so far.

“Latest RCR staffing data shows the NHS needs at least another 2,000 radiologists to meet demand and ensure safe practice. Recent training uplifts for more radiologists are welcome, but must go further to meet future demand. In the short-term Government, the NHS and trusts must work together to actively support and retain radiology teams, or risk an exodus of exhausted imaging staff.”