X-ray in January 2022
17. Mrs U complains the Trust failed to diagnose Mr U’s lung cancer in January 2022 when a chest X-ray showed Mr U had a tumour in his right lung. She complains the Trust did not act on this finding.
18. The RCR guidance for imaging reporting says reports should provide an accurate interpretation of images in a format that will prompt appropriate care for the patient. It also says when emergency imaging shows an incidental probable cancer, reporters may refer to the appropriate cancer multidisciplinary team meeting for discussion.
19. Our radiologist adviser said Mr U’s X-ray showed pleural plaques. However, she advised there was a soft tissue mass in the right lung which does not look like a pleural plaque. She explained there was also a similar area in the left lung which made it less obvious the right was abnormal. This is because it is unusual to have cancer in both lungs.
20. In line with RCR guidance for imaging reporting, the reporter should have suggested the patient have a CT scan at that stage. Our radiologist adviser explained this is because it is clear there was an abnormality that was different from pleural plaques.
21. Our radiologist adviser said the only exception to doing this would be if previous X-rays showed the abnormalities had been present for a long time. This is because radiologists compare any imaging to previous ones to check for any changes. However, the report at the time noted there had been no previous imaging for comparison.
22. Mr U then had two more X-rays on 10 March and 26 March which were also abnormal. It seems the radiographers who reported these scans relied on the report from the first X-ray and agreed with it. Again, this was not in line with the RCR guidance for imaging reporting as the radiographers should have suggested a CT scan based on the imaging.
23. The Trust’s complaint response acknowledged there was an error in the reporting of the X-ray on 31 January. It said it had asked a panel of radiologists to review Mr U’s imaging. The Trust explained the panel felt most radiologists would not have been happy to attribute all the shadowing on the X-ray to pleural plaques. It said most radiologists would have recommended a CT scan, but a significant number of radiologists may not have.
24. The Trust also acknowledged the cancer was visible on Mr U’s subsequent X-rays but said the initial X-ray had likely reassured the reporters. Our radiologist adviser explained although radiologists make comparisons to previous imaging, reporters should only be reassured if an abnormality had looked a particular way for many years rather than over a few months.
25. We acknowledge the Trust said international studies show around one in 20 radiology reports have some form of discrepancy or error. We can see the RCR guidance for radiology events and learning meetings outlines that discrepancies can occur in three to 30% of reports published in literature.
26. This guidance explains the difference between a discrepancy and an error. It says not all discrepancies are necessarily an error. It explains in some cases the original reporter has overlooked a radiological finding which the majority of radiologists should reasonably be expected to have seen. The guidance says that in such cases, the reporter has made an error.
27. We have found that most radiologists would have picked up on the abnormality on the X-ray on 22 January which the Trust acknowledged in its complaint response. We therefore consider there was a failing by the Trust in reviewing this. The Trust also missed further opportunities when reviewing the X-rays on 10 and 26 March.
Impact of failing
28. Mrs U says if the Trust had diagnosed Mr U sooner, he may have been well enough to have treatment and may have had more time. We understand why Mrs U was so concerned about this given the delay in diagnosis and we can see this is a continued source of distress to her.
29. The NICE lung cancer guidance states clinicians should arrange a CT scan to further the diagnosis and stage of the disease in a patient with suspected lung cancer. This guidance does not state how quickly this should occur. However, our oncologist adviser said this would usually occur urgently and within two weeks.
30. Our radiologist adviser said had the Trust performed a CT scan at this time, this would have shown Mr U’s cancer. This means the Trust would have diagnosed Mr U around the middle of February rather than September.
31. The national cancer waiting times guidance says treatment should occur within a maximum of 62 days from when the urgent referral for suspected cancer was made. This means Mr U likely would have started his treatment around early April at the latest.
32. Our oncologist adviser said it is now not possible to say, even on the balance of probabilities, whether treatment in April would or would not have given Mr U more time. He explained, it is possible treatment started when he was fitter and stronger to deal with chemotherapy may have given him a few more months, up to six months at the most.
33. However, he explained it is also possible it may not have given him more time. Mr U’s X-ray in January sadly showed he already had advanced lung cancer at that time and so we can say with some certainty that earlier treatment would not have cured him.
34. When he eventually had chemotherapy, Mr U struggled to tolerate it, having only one cycle before stopping. Our oncologist adviser said this may have been because he was weaker by this point. However, he explained Mr U may also have struggled had he started in April and may have only had the same amount of time even with earlier treatment.
35. The Oncologist meta-analysis looked at the difference between delayed versus immediate start of chemotherapy in asymptomatic patients (those without symptoms) with advanced cancer.
36. The limited evidence from this study suggests that delayed start of chemotherapy once symptoms occur (as was the case for Mr U) compared to immediate start in patients with no symptoms does not worsen overall survival. It showed that starting chemotherapy later once symptoms occur may be beneficial for patients in preserving their quality of life.
37. This study supports it was not necessarily detrimental to have delayed chemotherapy for Mr U. We recognise this was only one study which included patients with colorectal cancer, gastric cancer, and ovarian cancer. The meta-analysis recommended the need for further studies into the timing of the start of chemotherapy.
38. Taking into account the available evidence, we cannot say even on the balance of probabilities, whether earlier chemotherapy would have given Mr U up to six months longer to live. We recognise this leaves Mrs U with some uncertainty around this which is a significant injustice to her.
39. Mrs U told us Mr U began to experience pain in his left side a few weeks before diagnosis which she feels may have been related to his lung cancer. Our oncologist adviser said it is possible this pain was cancer related and if so, an earlier diagnosis would have allowed doctors to manage this more effectively. We can see the knowledge the Trust may have missed an opportunity to manage Mr U’s symptoms is a further source of distress to Mrs U.
40. Mr U died only months after eventually being diagnosed. The delay in diagnosis meant Mr and Mrs U lost the opportunity to prepare, focus on spending quality time together, and make memories. This is a significant loss of time, and we recognise the affect this has had on Mrs U.
41. We have considered what the Trust has already done to remedy this complaint. Mrs U told us one of the outcomes she would like is service improvements to ensure similar mistakes do not occur again.
42. The RCR guidance for radiology events and learning meetings recommends that in the event of a discrepancy or error, the responsible clinician should inform the primary reporter in the interests of peer-to-peer learning. It also advises discussing any discrepancies in a Radiology Events and Learning Meeting.
43. We can see the Trust has completed both these actions because of Mrs U’s complaint and the discrepancies it identified. We are reassured the Trust has taken learning from Mrs U’s complaint in line with our Principles for Remedy and so we have not made any further recommendations to the Trust in this regard.
44. Similarly, we can see the Trust correctly acknowledged the radiological error during its handling of the complaint. In a complaints meeting Mrs U attended with the Trust in July 2023, the Trust acknowledged the distress and impact the errors caused her.
45. However, we do not feel an apology alone goes far enough in recognising the impact these issues had on Mrs U. We now cannot change what has happened however, we have recommended the Trust should pay Mrs U a financial remedy in recognition of the distress the failings caused. We have explained this in the recommendations section of this report.
MRCP March 2022
46. Mrs U says the Trust missed a further opportunity to diagnose Mr U’s cancer in March when an MRCP scan also showed the tumour.
47. In its response to this complaint, the Trust acknowledged the right lung mass is visible, in hindsight, at the edge of a few of one of several images from his MRCP scan. We can see the radiologist did not comment on this in their report. The Trust said its panel of radiologists felt the majority of radiologists would not have commented on it either.
48. The RCR guidance for imaging reporting is again relevant here which says radiologists should report any incidental findings to the referrers. The RCR guidance for events and learning regarding the difference between a discrepancy and an error is also relevant.
49. We can see the Trust requested this scan to examine Mr U’s liver. Our radiologist adviser said for some reason the radiographer also scanned more of the lung than is usual. The scan showed the lung cancer visible on the edge of some of the images.
50. Our radiologist adviser said some radiologists would have identified this and others may not have. However, she explained that, overall, a significant number of radiologists would have missed this because it was at the edge of the image, it was not clear, and they were looking at the liver not the lung.
51. Taking this advice into account, we have not found the Trust acted outside the RCR guidance for imaging reporting by not recommending a CT scan at this time. This is because the majority of radiologists would not have reported this. We have found no failings in this part of the complaint.
52. We understand why Mrs U was so concerned about this and we hope our findings provide her with some reassurance on this issue.