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.

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