Case study 2: Radiology

Cameron, a 53 year old lone parent of two teenage children, goes to see his GP complaining of neck pain after falling from a step-ladder. His GP refers him for x-rays of his cervical spine. The x-ray was reported as showing moderate degenerative changes but no fracture or dislocation.

Six months later, Cameron returns to the GP surgery complaining of a persistent cough, which is particularly bad in the mornings. He had assumed this was a ‘smokers’ cough’ and hadn’t been concerned until three days ago when he coughed up flecks of blood. His GP refers him for an urgent chest x-ray.

Dr Wesley, a consultant radiologist, in the course of reporting on Cameron’s chest X-ray, identifies a large mass at the apex of the right lung. She notes that Cameron had had an X-ray of his cervical spine six months earlier and, on reviewing this she notes that the mass is clearly visible – albeit smaller – at the edge of the film.

The mass is confirmed on CT scan and biopsy as a primary lung tumour that has metastasised. The tumour is deemed to be inoperable and an oncology team takes over Cameron's care. Cameron is distraught by the diagnosis and starts to withdraw from his friends and family.

The radiologist who reported the previous film no longer works for the hospital and has not left any contact details.

What should Dr Wesley do?

  • Should she ignore the previous cervical spine x-ray because it would be of no help to Cameron now to know that the tumour could have been identified six months ago?
  • Should she arrange to meet Cameron (who she has never met) to discuss the fact that the tumour was clearly visible on the cervical spine x-ray, and so could have been diagnosed six months earlier?
  • Should she inform Cameron's oncology team, who will be able to tell him that the tumour had been visible earlier?
  • What should Dr Wesley write in her report about the previous radiology report? And should she contact the radiologist responsible for it beforehand?

Who should speak to the patient?

In paragraph 5 of Openness and honesty we say that, although we don't expect everyone involved in a patient’s care to take responsibility for reporting adverse incidents and speaking to patients if things go wrong, we do expect professionals covered by the duty (ie doctors, nurses and midwives) to make sure that someone in the team has taken on this responsibility. In paragraph 9 we say that the most appropriate team member will usually be the lead or accountable clinician. It’s important that the patient’s needs are considered and, if Cameron has developed a good relationship with his consultant oncologist, it may well be that he or she is the best placed person to disclose the information. Dr Wesley should speak to the oncologist to help make a decision about who should speak to Cameron. The oncologist will also best appreciate the consequences of late diagnosis and the resultant changes in treatment options, side effects and prognosis for Cameron.

Would the patient be better off not knowing?

The message that we received from patient groups during the consultation was clear: however unwelcome the news of an error may be, and even if it’s too late to change the outcome, it would not be acceptable for the doctor, nurse or midwife to withhold that information from the patient. This is particularly true if, as in this case, the error means an opportunity to start treatment earlier was missed.

In paragraph 12 of Openness and honesty we say that patients will normally want to know more about what has happened, but we also say that you should give them the opportunity not to be given every detail. If the patient does not want more information you should try to find out why.

In paragraph 15 we say that when apologising and explaining what has happened we do not expect you to take personal responsibility for something that was not your fault (such as system errors or a colleague's mistake). But we say that the patient has a right to an apology from the most appropriate team member, regardless of who or what may be responsible for what has happened.

What should Dr Wesley write in her report about the previous radiology report? And should she contact the radiologist responsible for it beforehand?

In writing her report, Dr Wesley should remain objective and avoid statements such as that the lesion “should” have been seen before or that it was “understandable” that it was not seen and reported.

Ideally Dr Wesley should contact the previous radiologist as soon as practical after discovering the error so that they are aware of it and can reflect on – and adjust – their practice as necessary to reduce the likelihood of it occurring again.

However, it will not always be possible to contact the reporter of the previous Xray: increasingly radiology reporting is carried out by teleradiology from another part of the UK or abroad; and the reporter – who may be a radiographer rather than a radiologist – may be employed by a private company, not the NHS Trust which employs Dr Wesley.

Whether or not she is able to contact the previous reporter, Dr Wesley should refer the case – anonymised where possible – to a “Learning from Reporting Discrepancies” or “QA” meeting so that other radiologists can learn from the event and hopefully help to reduce the chance of it occurring again. This is in line with paragraphs 22-26 of Openness and honesty which emphasises how important it is to report at an early stage so that lessons are learnt quickly and patients protected from harm in the future.

The Royal College of Radiologists has a dedicated system for sharing incidents and discrepancies across the specialty: the or READ system. READ is ...

  • A confidential system for sharing incidents, events and discrepancies in radiology, accessible to all members and Fellows of the RCR
  • A learning tool to support best practice and to contribute to improved patient safety
  • An educational resource designed to promote safety in radiological practice, within both the NHS and the independent sector.