Review of 46,000 radiology scans at University Hospital Kerry
ELEVEN patients, including a number who had cancer, suffered a delayed diagnosis due to hospital X-ray and scan failures, a new report revealed today.
The review of X-rays at Kerry General Hospital in Tralee found four of the patients have died.
The investigation was called for in summer 2017 after three very ill patients were discovered to have cancer only after they came back to the hospital in July and August.
They had got the all-clear weeks earlier.
Four more patients returned to the hospital in the autumn, complaining of ongoing symptoms. They were delivered the shock news that they were victims of delayed diagnosis and had been given incorrect results.
This led to the suspension of a radiologist and a look back at 46,234 images - CT Scans, Ultrasound Scans and Chest X-Rays.
The radiologist is no longer working with the hospital.
A report on the review from the South SouthWest Hospital group today said: "Eleven patients had their diagnosis delayed which had a serious impact on their health, including the initial three cases which prompted the review.
"The look-back found three patients with undiagnosed cancer, which had not previously been identified.
"Regrettably four of the eleven patients have passed away in the intervening time period between identifying their delay and the publication of the look-back report."
The purpose of the extensive review was to identify and address patient safety issues and to ensure patients were informed and had access to follow-up care if necessary.
The peer review audit was grouped into three categories, Score 1, Score 2, and Score 3.
- 44,831 were given a Score 1. This indicated there was agreement with original report or a minor abnormality of no on-going clinical significance.
- 1,298 were given a Score 2. This related to an unreported finding that was unlikely to be of clinical significance, however, it required a review by a Clinical Subgroup. The patient may require rescanning.
- 105 were given a Score 3. This required immediate communication to a Clinical Subgroup as the previously unreported finding was of potential or definitive significant clinical concern.
All these cases are the subject of further on-going system analysis review investigations, which are being shared with individual patients and their families.
Dr Gerard O’Callaghan, Chair of the SIMT said :“I would like to thank the patients and their families for the courtesy and understanding shown by them to the hospital staff in the course of this review. This cannot have been easy particularly when having to deal with devastating news which would have had a profound effect on them and their families.”
The look-back review found that there was a substantial rate of unreported clinically significant findings requiring clinical review to determine if patients should be recalled for imaging. The review was designed to identify patients who may need on-going and additional care and was not an individual professional review.
A key finding of the audit noted that while patients were exposed to risk, the majority of patients did not suffer any direct harm due to the diligence of their treating Doctors.
A number of patients were discovered to have unrelated diagnoses where the diagnosis was made on repeat imaging and was not found to be present or visible, even in retrospect on the original radiological examination reported.
The participation of these patients therefore in the recall process has been responsible for detecting these diagnoses. These patients are now in appropriate care or surveillance pathways.
Dr Gerard O’Callaghan, Chair of the SIMT added:“This was the biggest radiology look-back carried out in this country. It was carried out very professionally in a very short time period by dedicated hospital staff at UHK who went over and above their normal duties to complete the process as judiciously as possible whilst at the same time keeping the patients at the centre of all efforts and decisions. I would also like to express my thanks to the external radiology and medical staff as well as staff in the SSWHG for their support during this process.”
An external review of the X-ray department in the hospital has been commissioned.