QA Hospital chest x-ray backlog that saw two patients die was '˜within accepted error rate'

Verita carried out an inquiry on behalf of Portsmouth Hospitals NHS Trust, which runs the Cosham site, after the Care Quality Commission found last year there was a backlog of 30,221 scans. The chest and abdomen X-rays were from A&E patients between April 2016 and March last year.

They were reviewed by medical staff not trained to see subtle signs that could be serious illnesses. Two patients died after doctors did not spot lung cancers.

As reported in The News, medical director John Knighton told the trust board in February there were around 20 possible cases of missed lesions and one was identified as an incident of severe harm.

Verita’s report, which will be presented to the PHT board meeting on Thursday, said: ‘There is a generally accepted error rate in the interpretation of a plain film by a skilled, experienced radiologist of between three-and-a-half to five per cent.

‘Unless the conclusions of the Harm Review change radically after this report is finalised, the numbers of patients identified as suffering harm as a result of the failure of PHT to adhere to its Plain Film Evaluation and Reporting Policy fall very significantly within the accepted error rate of a qualified radiologist.’

It added: ‘Although we have identified significant issues with the way that the policy was governed, the de facto decision taken by the department not to routinely report on A&E plain films would have been justifiable, particularly in light of the huge resource constraints and competing demands on radiologist time.’

The report said the backlog was ‘regrettable’ but the ‘radiology department exercised good clinical judgement’.