13. We looked first at what happened in November 2022, and whether this was in line with guidance. Mr A was admitted with limited responsiveness following a seizure. The records show the Trust undertook a thorough assessment by carrying out observations, tests and examinations, and looked at his recent and previous medical history. The Trust arranged imaging of his head, chest, abdomen and pelvis to investigate the causes of his symptoms and help make a diagnosis. The CT scan of his abdomen and pelvis suggested he had a small bowel obstruction.
14. The Trust arranged a CT pulmonary angiogram (a specialised CT scan using contrast dye to look at the arteries that carry blood to the lungs and look for blood clots in the lungs) to exclude a pulmonary embolus (blood clot in the lung).
15. Our physician adviser told us the actions of the Trust were in line with the GMC guidance Good Medical Practice which says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.’
16. It is the reporting of these CT images that Mrs V has raised concerns about. For this reason we asked our radiology adviser if what happened when the images were reported was in line with guidance.
17. Mr A was admitted having been found unconscious. The records note his history of epilepsy, secondary to a traumatic brain injury in childhood. Our adviser considered the Trust properly arranged imaging of his head, chest, abdomen and pelvis to look for any causes of his collapse and help to make a diagnosis.
18. The medical records show the imaging was requested to investigate whether there had been a bleed in the head, whether there was a blood clot in the lungs. It was also to check whether there was an ischaemic bowel (problem caused by reduced blood flow to the bowel) or any other problem in the abdomen to account for Mr A’s collapse.
19. The images were reported initially by a radiology registrar (a trainee doctor). The doctor compared the imaging with previous imaging, where available. There were a large number of images to review and this was completed overnight, in a busy trust providing inpatient and emergency care.
20. Our radiology adviser told us the large number of images and scans, and the extensive issues to be checked, will have taken a long time to consider and report. It was our radiology adviser’s opinion that the doctor provided thorough and detailed reports of all the images and addressed the clinical questions raised. The images and the reports were then reviewed and verified by a consultant radiologist the next morning.
21. The relevant guidance for reporting imaging is the Royal College of Radiologists (RCR) ‘Standards for interpretation and reporting of imaging investigations’. This sets out clear guidance to ensure radiology reports are accurate, consistent, clinically useful, and timely. It emphasises structured reporting, inclusion of relevant clinical and technical details, and communication of critical findings to support safe patient care.
22. Taking into account the views of our radiology adviser we found the reports were completed in line with the guidance. They met requirements one to four which say:
‘1. 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.
2. The wording of the report should be unambiguous and should take into account the professional background of the referrer. Further investigations or specialist referral should be suggested within the report when they contribute to patient management.
3. When reporting imaging studies, the reporter should take into account and review pertinent prior studies from the same and different imaging modalities, all the relevant clinical information, laboratory results and histopathology reports.
4. Where there is a need for a long, descriptive report, it should conclude with a short summary of key findings and their interpretation (with appropriate clinical advice on the next step of management, if appropriate).’
23. The imaging and the reports were reviewed by a consultant the next day, and this was also in line with the RCR guidance which says: ‘Radiologists, and other reporting doctors, should have access to a second opinion from a radiologist at the time of reporting, or soon afterwards, if required.’
24. In relation to the suspected cause of Mr A’s symptoms, it was reasonable and in line with the guidance in paragraph 22 that the imaging properly identified and reported a ‘small patch of right basal consolidation is likely infective and given the fluid-filled oesophagus possibly represents an aspiration pneumonia and this guided ongoing treatment’.
25. This means the right lung had an area that was not air filled as usually expected, but instead seemed to have infection. This was a reasonable conclusion to reach, and in line with point one of the guidance. It is the opinion of our radiology adviser that there is nothing to suggest this was anything other than what was reported.
26. Our radiology adviser reviewed the imaging and could see the reports did not identify the 7mm nodule in the left upper lobe of the lungs. They told us the nodule is in the same place as the cancer that was later identified in 2024. We agree this was a missed opportunity to identify cancer, and potentially offer a curative treatment, to prevent its progression and Mr A’s sad death.
27. We cannot say the fact that the nodule was not observed on this occasion was a failing, or that the actions of the practitioners were unreasonable or outside the guidance. The RCR Standards acknowledges that some level of discrepancy is inevitable in radiology reporting:
‘A reporting discrepancy occurs when a retrospective review, or subsequent information about patient outcome, leads to an opinion different from that expressed in the original radiological study report. Reporting discrepancies are common (between 3–30% of reports in published literature) and have many causes’.
28. Our radiology adviser explained they had identified the nodule on review of the images, being already aware that there was a nodule to look for, thus making it easy to see. They said when reporting a scan like this, that has been ordered for a specific reason, it becomes much more difficult to identify an incidental finding like this nodule. We do not conclude it was a failing that the original reporters did not identify it, given the context when they examined the images, as outlined in paragraphs 18, 19 and 20 of this report.
29. Our finding is supported by the information we outline in paragraphs 53 to 61 about the additional actions the Trust took once this discrepancy between the imaging and the report was identified.
30. We understand it will be difficult for Mrs V to read that there can be times when clinically significant findings are not identified, and that this does not always constitute service failure. We recognise that this can have real life consequences and are truly sorry that this will leave unanswered questions about what might have happened if the nodule had been identified.
31. It was reasonable for the doctors treating Mr A to rely on the report of the imaging in providing the care and treatment during this admission. With the retrospective knowledge that we now have we know it will cause Mrs V upset to read this, and we are truly sorry.
32. The report excluded a pulmonary embolus and showed Mr A had an area of consolidation in the base of the right lung. The doctors treating Mr A made a likely diagnosis of aspiration pneumonia. This is a type of pneumonia that is caused by bacteria entering the lungs from the stomach and causing a severe infection, which can occur following a seizure and if the bowel is obstructed. Our physician adviser said this was a reasonable diagnosis to make based on Mr A’s recent history of seizure, his raised markers of inflammation and the report of the imaging.
33. The Trust arranged for Mr A to be reviewed by specialists from the intensive treatment unit (ITU), general surgery and acute internal medicine to make sure there were no issues that had been overlooked, or that needed investigation or treatment.
34. The Trust started treatment with broad spectrum antibiotics for the aspiration pneumonia. This was in line with the NICE guidance ‘Summary of antimicrobial prescribing guidance – managing common infections’. This recommends starting treatment with antibiotics as soon as possible after diagnosis, which is what happened.
35. The Trust followed this guidance by starting treatment with intravenous antibiotics and changing to two different oral ones, keeping the antibiotics under review. This way the Trust balanced the severity of symptoms, the number of days in hospital before onset of symptoms, the risk of developing complications, and the risk of adverse effects.
36. Before discharge the Trust looked at Mr A’s nutrition needs and made a referral to a dietician. They also obtained a neurology opinion, because of his past history of brain trauma and presentation with seizure. The neurology team recommended changes to his anti-epileptic medication which were made during the admission. The Trust had found vertebral wedge fractures and so made an outpatient referral to the bone clinic.
37. The care and treatment outlined in paragraphs 32, 33 and 38 were in line with the GMC guidance which says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.’
And
‘In providing clinical care you must: a prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b provide effective treatments based on the best available evidence c take all possible steps to alleviate pain and distress whether or not a cure may be possible d consult colleagues where appropriate’
38. Mrs V also raised concern that the doctors who saw her brother during the clinic appointments outlined in the complaint summary did not identify that anything was wrong, and so did not take action that would have led to an earlier diagnosis of cancer.
39. We looked first at the appointments with the endocrinology clinic. We asked our endocrinology adviser if there was anything to show the doctors should have taken different actions. Our adviser went through each appointment and gave their views.
40. In January 2023 Mr A had a general endocrine clinic appointment with Mrs V, carried out by telephone. Telephone appointments became common practice at this time, following COVID-19.
41. During this appointment the consultant took a history of Mr A’s current condition, recent history and symptoms, and noted referrals to other specialisms. It noted his medication and his recent blood test results. The clinic letter did not identify any changes were needed to the current treatment plan and planned a review in around nine months.
42. The next appointment was in August 2023. This was also a telephone appointment, where the registrar spoke to Mrs V. Again the appointment reviewed Mr A’s current condition, recent history and symptoms, and noted referrals to other specialisms. It noted his medication and his recent blood test results. It is clear Mr A faced significant difficulties with his care and the doctor took detailed notes of the information Mrs V shared.
43. The final appointment considered by our endocrinology adviser was at the end of August 2023. This was a face to face appointment with Mr A, with Mrs V present. The clinic letter shows the doctor reviewed Mr A’s current condition, recent history and symptoms, and noted referrals to other specialisms. It noted his medication and his recent blood test results.
44. The doctor gave advice to Mr A about changes in medication for his bone health. They also noted his heavy smoking habit and gave advice to give up, because of the increased risk of osteonecrosis of the jaw (a rare condition where jawbone tissue dies and becomes exposed through the gums, often linked to drugs used for osteoporosis).
45. Our endocrinology adviser told us these appointments were in line with the GMC guidance, as outlined in paragraph 37. In listening to Mrs V and sharing the information they did, the consultations were also in line with the part of the GMC guidance that says:
‘You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’
And
‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’
46. Our endocrinology adviser added that there was nothing in these consultations to make the doctors think there were any red flags for cancer, or that they should make any additional referrals.
47. We next looked at the appointments with the neurology clinic. We asked our neurology adviser if the actions the doctors took in April 2023 and February 2024 were in line with guidance.
48. Our neurology adviser explained it would not be expected or appropriate for the neurologists to have reviewed any imaging unrelated to their specialism, or to review the respiratory records. This expectation is outlined in the GMC guidance which says: ‘Recognise and work within the limits of your competence’.
49. During these appointments the doctors noted a detailed history of Mr A’s condition and diagnosis, his medications, recent history, symptoms and treatment plan. The second letter also made a referral to the GP and noted a referral the neurology service had made for an MRI and video telemetry (a diagnostic test that records a patient's brainwaves to capture and analyse seizures).
50. The records show Mr A had mesial temporal sclerosis (scarring and neuron loss in the brain's memory centre, the most common cause of focal temporal lobe epilepsy). This is a condition that is difficult to treat. The consultations properly recognised that medication was not effective in preventing his seizures, and that surgery would be the most effective treatment.
51. As was the case with the other clinic appointments, there was nothing within these consultations to suggest to the doctors that there were any red flags for cancer, or that they should make any additional referrals.
52. Our neurology adviser also said the appointments were in line with the GMC guidance referred to in paragraph 37.
53. In order to be reassured that it was not a failing that the Trust had not reported the nodule in November 2022, we looked at the actions the Trust took once Mr A was sadly diagnosed with cancer.
54. The guidance that explains what should happen in such circumstances is the RCR ‘Professional duty of candour, Guidance for radiologists’ and the RCR ‘Standards for radiology events and learning meetings’. Both documents place a responsibility on radiologists to identify if missed results were avoidable, and to take appropriate action and learn from what happened.
55. The Professional duty of candour guidance explains:
‘A discrepancy is defined as where the contemporaneous interpretation of an imaging study (usually in the form of a report) is different from (ie, discrepant with) a retrospective reinterpretation of that study, sometimes occurring in light of further information which might include further imaging.
A discrepancy assessment is a process to assess a discrepancy against an audit standard. An appropriate audit standard is that the contemporaneous interpretation of the imaging (usually in the form of a report) is as complete and comprehensive as would be reasonably expected given information available at the time the report was issued.’
56. This means that if a Trust later finds out that something has been missed there should be a process to see if the discrepancy could reasonably have been avoided.
57. In this case we can see the Trust acted in line with the guidance by carrying out a discrepancy assessment. The images and report were reviewed by six peers, and then reviewed again in light of the retrospective knowledge that became available about Mr A’s subsequent imaging and diagnosis.
58. The outcome of the assessment was that two radiologists considered the report of the imaging satisfactory, two did not think the missed nodule was easily identifiable, and two considered the missed nodule was identifiable and the discrepancy was avoidable.
59. Our radiology adviser told us this discrepancy review was the correct action to take and reached a reasonable conclusion, that the majority of those looking at the images did not think the nodule was easily identifiable.
60. The Trust explained the nodule was present on 6 out of the 900 images that the doctors examined, and this is a possible reason for what happened. Our radiology adviser said this was a reasonable conclusion to reach. The Trust took the correct action by discussing the discrepancy with the reporting radiologists for reflection. It also presented what happened as an anonymised case at the radiology education and learning meeting (REALM).
61. This was in line with what the ‘Standards for radiology events and learning meetings’ says: ‘… The primary reporter should be informed by the notifier in the interests of peer-to-peer learning. […] All discrepancy cases, whether they are errors or not, can be submitted to the REALM for anonymous discussion if there are useful learning points to be made.’
62. We understand why Mrs V thinks there were failings on the part of the Trust in not identifying the nodule sooner. We are so sorry for the distress this caused her, and for the ongoing thoughts she will have that the outcome could have been different.
63. We hope this report explains the reasons why we have not found failings, and that Mrs V is reassured about the actions the Trust has taken since.