UHBW CT imaging 16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
17. Mrs C complains that on 19 June 2023, when Mrs V had a brain scan due to reported ‘short term memory impairment’, staff did not identify an abnormality. An abnormality was subsequently identified after another scan 6 weeks later on 27 July.
18. Section 1.2.26 of NG97 says that if investigations are required, MRI would be preferable but if unavailable or contraindicated, CT is appropriate. Our clinical adviser says that in the UK, initial ‘screening’ imaging for cognitive impairment in the elderly is almost exclusively CT-based and is performed without contrast. This means that UHBW’s decision to perform a CT scan without contrast on Mrs V was appropriate and in line current practice.
19. Standard 1 of the RCR standards for interpretation and reporting of imaging investigations says, ‘a radiology report should be actionable and prompt appropriate care for the patient. It should answer the clinical question and include a tentative or differential diagnosis when an abnormality is seen and relevant negative observations if pertinent.’
20. The radiology report from 19 June describes positive and negative findings relevant to the clinical request. No actionable abnormalities were identified.
21. When Mrs C complained that staff had missed an abnormality from the 19 June scan, staff reviewed this scan. The Trust considered it which is in line with standard 1 of the RCR standards for interpretation and reporting of imaging investigations.
22. When reviewing the images, the UHBW took into consideration the concept of hindsight bias. This is outlined in the RCR Standards for Radiology Events and Learning Meetings, which explains that a review of cases takes place in the setting of [a radiology review meeting with all information available] rather than the setting in which the original report was issued. This means the review would take into account everything that was now known, rather than just the information available when the first scan was reported on 19 June.
23. UHBW also refer to the concept of discrepancy within its Patient Safety Investigation. It explains a discrepancy as, ‘when a retrospective review, or subsequent information about a patient outcome, leads to a different opinion from that in the original radiological study report’. It goes on to say that ‘in some discrepancy cases, it is only with the benefit of hindsight… that the radiological finding could have reasonably expected to be identified. If the majority of radiologists would not have reported the finding [at the time], it is not an error’.
24. UHBW’s Divisional Patient Safety Investigation describes a radiology panel review where the initial study of 19 June was provided to five radiologists blinded to the subsequent tumour location. UHBW’s report states that ‘none were able to definitively identify the tumour location before the second scan…was revealed’.
25. UHBW’s response and its approach to its investigation meets the current Royal College of Radiologist standards for review of and learning from a discrepancy.
26. We understand Mrs C’s concerns that an abnormality in the scan completed on 19 June was not identified, given that an abnormality was identified six weeks later. The evidence indicates that the original radiology report from 19 June was reported correctly, and the review of the scans were completed in line with the relevant standards.
27. We are deeply sorry to hear about the upset Mrs C has suffered and how she has been affected. We understand how much this complaint means to her and thank her for sharing the details.
North Bristol Trust
Patient Transfer 28. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found North Bristol Trust has already done enough to put right the impact of these events.
29. Mrs C complains that when her mother needed hospital transportation booking staff did not provide full details of her condition to the transfer staff, meaning that she did not receive adequate supervision.
30. North Bristol Trust acknowledges there was missing information in the transfer booking meaning that the ambulance staff were not fully aware of Mrs V’s vulnerabilities.
31. Our Principles of Remedy outline that the public body should take steps to provide an appropriate and proportionate remedy to the complaint.
32. We have considered what steps the Trust has taken in response to Mrs C’s complaint and whether these actions go far enough to put things right for Mrs C and prevent a recurrence.
33. The Trust has taken positive steps to address what happened and the impact to Mrs C. These are outlined in its complaint response dated 3 October 2023. The Trust has apologised to Mrs C for its failure to provide details of her mother’s confusion and acknowledges how distressing the events were for Mrs C.
34. North Bristol Trust has ensured that all transfer staff have been made aware of the incident. Details of the incident have been shared in the form a patient story highlighting the impact on both Mrs C and Mrs V and how the incident could have been prevented. As a direct result of Mrs C’s complaint, North Bristol Trust have also developed a new transfer of care document that is used when a patient is being transferred to another acute care facility. They confirm this document is given to the ambulance transfer crew and sent with the patient to the receiving hospital or care home.
35. We consider the actions proportionate to resolve the matter. We will therefore take no further action. We understand that the complaint is very important to Mrs C, and we thank her for bringing her concerns to our attention. We hope this statement clearly explains the reasons why we will not be considering the complaint further.