17. RCR standards say radiological reports should be produced, read and acted upon in a timely fashion. It is the responsibility of the radiologist to produce reports as quickly and efficiently as possible, and to flag reports when they feel a fail-safe alert is required. It is the responsibility of the requesting doctor and/or clinical team to read and act upon the findings and fail-safe alerts as quickly and efficiently as possible.
18. GMC guidance says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary.
19. Despite the above guidance, in 2022 there were no national times for performing and reporting on scans. Our radiology adviser said generally radiology departments tried to report on the most urgent scans, such as those for suspected cancer, within seven days.
20. We can see that once Mr B’s CTPA was completed on 19 April, a radiologist reported the results of this seven days later. The report highlighted that there was a pulmonary embolism present. Our radiology adviser said this was quite subtle but had been correctly identified by the radiologist.
21. The RCR standards do not give examples of what might be considered critical and urgent findings requiring a fail-safe alert to be sent to the referring doctor. However, our radiology adviser said a pulmonary embolism is a finding that should have been sent via the Trust’s local alert notification process.
22. The NICE guidance say when a person has suspected pulmonary embolism, they should be admitted to hospital immediately. This demonstrates the urgency of a pulmonary embolism. Therefore, in line with the RCR standards, the radiologist should have sent the CTPA report using the Trust’s fail-safe system.
23. In its response, the Trust said the report was sent with non-urgent results. It is not clear from the records when the doctor received the CTPA report from radiology, but we know they reviewed it on 19 May.
24. Our physician adviser said it could be several weeks before a doctor reviews routine results but those flagged as urgent would be acted on the same day. This would be in line with the GMC guidance at paragraph 18.
25. The doctor wrote to Mr B’s GP the same day, with the letter copied to Mr B. This was to inform them that due to the CTPA findings, they had referred Mr B urgently to its ambulatory emergency care (AEC) department. This is a department which provides same day hospital care. The plan was for him to be assessed and treated with blood thinning medication. He would be admitted if necessary.
26. This planned action would have been in line with the NICE guidance for arranging immediate hospital treatment. However, this did not happen. It appears the doctor’s referral was not acted upon by the relevant department.
27. This means the first Mr B knew of the pulmonary embolism was on 24 May when he received the letter the doctor had copied to him. His visiting nurse then arranged his urgent admission to hospital.
28. The Trust firstly failed to ensure the report of the CTPA was flagged as needing urgent review. Then once the doctor had reviewed the report and planned appropriate care and treatment, the Trust failed to arrange his attendance at hospital so this could happen.
Impact of these failings
29. The failures identified above led to a four week delay in Mr B receiving treatment for pulmonary embolism. We have considered if this had any clinical impact on Mr B.
30. The purpose of blood thinning treatment given for pulmonary embolism is to prevent the clot from getting bigger and to prevent new clots forming. Mr B did not have a further CTPA scan before receiving treatment and therefore we do not know if the clot got any bigger or if new clots formed while he was without treatment.
31. Our physician adviser said the clinical findings indicate the pulmonary embolism was not contributing significantly to Mr B’s overall poor clinical condition. Specifically, he only had a low temperature and low oxygen saturation levels. However, Mr B always had low oxygen saturation levels as he was a long-term oxygen therapy user. They said his clinical presentation was of complications of heart failure.
32. Looking at Mr B’s condition before the pulmonary embolism was identified, he already had established right sided heart failure. Tests had previously shown that his right sided heart function was severely impaired.
33. Mr B died from heart failure alongside multiple contributing factors. This included chronic obstructive pulmonary disease (COPD), sleep apnoea, removal of part of the lung due to lung cancer and the pulmonary embolism.
34. Sadly, he was already in precarious health before the pulmonary embolism was identified. Our physician adviser said based on the evidence it is unlikely the pulmonary embolism contributed to Mr B’s death. They said it is difficult to say with any certainty whether what happened worsened Mr B’s heart failure and therefore contributed to his death.
35. Overall, we have found it is unlikely the failings contributed to Mr B’s sad death. However, we cannot say with certainty that it did not have any impact on him. This has left Mrs B with some doubt about what might have been, about whether she and her husband may have had a little more time together. We acknowledge and do not doubt the pain this uncertainty causes her. We recognise these doubts prevent her from getting closure to the circumstances of her husband’s death.
36. The Trust has acknowledged in its complaint response some shortcomings in relation to the CTPA. However, it has not clearly acknowledged the failures we have identified. Nor has it apologised for the emotional impact these had on Mrs B. We have therefore made recommendations below for the Trust to take further action.