16. Mr G complains the Organisation did not recognise he had a stone in his CBD when it carried out an ultrasound scan on 14 December 2023. He has told us he was in pain for longer than was necessary as it would have referred him for follow up treatment sooner. He was also unnecessarily anxious about what was causing his symptoms.
17. The Organisation wrote a report which it sent to Mr G’s GP when it completed the ultrasound. It said:
‘FINDINGS: The liver is smooth in outline but demonstrates increased echogenicity throughout; this is suggestive of fatty infiltration. Correct direction flow seen within the portal vein on colour Doppler. No intra or extra hepatic duct dilation seen. The gallbladder, spleen and both kidneys and visualised aorta are sonographically normal. The pancreas was obscured by over lying bowel gas. No upper abdominal free fluid.
IMPRESSION: Fatty liver.’
18. The Organisation considered its report and spoke with the sonographer when it investigated Mr G’s complaint. The report is clear the CBD was seen as it is part of the extra hepatic system and it states, ‘no intra or extra hepatic duct dilation seen.’ The complaint response acknowledged the sonographer could not see the CBD during the ultrasound scan. It said the report it sent to Mr G’s GP was not accurate as the sonographer could not confidently say there was no extra hepatic duct dilation (which would have indicated a stone) as they did not see the CBD.
19. Our adviser told us sonographers should follow the Society of Radiographers (SoR) and British Medical Ultrasound Society’s (BMUS) ‘Guidelines for Professional Ultrasound Practice’ when carrying out ultrasounds. Section 4.5 makes recommendations for sonographers when they are producing the ultrasound report. It says ‘the report author should take responsibility for the accuracy of the report’ and ‘the report author should be aware at all times of the implications for the patient of the contents of the report.’
20. We have found the Organisation did not follow this guidance. The report was not accurate. There were implications for Mr G as a result of the inaccuracies, and we have looked a this in more detail in the next section of this report.
21. We are not critical of the Organisation for not being able to view the CBD. It is not always possible to view each organ during an abdominal ultrasound. The key issue here is now it was recorded in the report, which is what we are taking a view on. The guidance does provide more information on what sonographers should do if they are carrying out a difficult ultrasound. It says:
‘Ultrasound is an operator-dependent technique and the diagnostic quality of the images relies very much on the skills of the operator. The person interpreting and reporting the images must be able to reflect critically on the image quality and appraise the impact on diagnostic accuracy. Where the images are technically suboptimal (e.g. high patient BMI), the reporting author must decide whether the patient requires recall and rescan. It is recommended that any technical limitations of a scan are clearly recorded in the report.’
22. The Organisation did not follow this guidance. It did not clearly record the technical difficulties it faced in Mr G’s ultrasound scan. Our adviser has highlighted an image within the Organisation’s records which does show the area of Mr G’s extra hepatic system but it is not clear. The Organisation should have included this in its report and considered if Mr G needed a re-scan.
23. Our adviser also explained there are ways the sonographer could have adjusted their equipment which could have potentially improved the quality of this image. They said the sonographer could have increased the gain of the image, which increases brightness. They could also have reduced the frequencies which could have produced a clearer image of the extra hepatic system. This is further evidence to support our view that the Organisation did not follow the guidance on completing a difficult ultrasound.
24. We have found the Organisation did not follow the SoR and BMUS guidance when it carried our Mr G’s ultrasound in December 2023 and it produced an inaccurate report. We cannot see the sonographer reflected critically on the quality of the images. We have found this to be a failing.
The impact the Organisation’s failings had on Mr G
25. Mr G has told us the Organisation’s mistake meant he was in pain for longer than was necessary and he was anxious about what was causing him the abdominal pain.
26. We acknowledge it is likely Mr G would have been referred for follow up treatment sooner than he was if the Organisation had seen a stone in his CBD. As we have set out above, we do not think we can say the Organisation being unable to view the CBD was a failing in itself. We have found it should have reported the scan differently. This may have led to further investigations and an earlier diagnosis of the CBD stone, but we cannot know on the balance of probabilities. This is because there would have been several steps between that first scan and a diagnosis, including at least a further scan (we do not know if this would have clearly shown the CBD) and clinical decisions that we can only speculate about. It is also important to note Mr G never actually received any direct treatment for the stone in his CBD. It passed naturally and his CBD was confirmed to be clear in January 2025. So the evidence does not allow us to conclude he was in pain for longer than he would have been.
27. But we appreciate the uncertainty and anxiety this caused for Mr G. He learned he had a CBD stone in May 2024. His symptoms had been present since before the ultrasound scan the Organisation completed so we think it is more likely than not he had a stone in his CBD in December 2023. When he found out about the stone, about five months after the first scan, he was anxious about the impact of the delay. This compounded the worry he had while he waited for further investigations and treatment options, which happened from August.
28. Fortunately, he did not need treatment, but this does not take away from the impact the Organisation’s mistakes caused Mr G. If he had known the limitations of the December 2023 scan, he would have been better informed and this may have reduced his worry and anxiety.
What the Organisation has done to put things right
29. The Organisation responded to Mr G’s complaint in July 2024. We have already set out that the complaint response acknowledged that the Organisation had incorrectly reported the ultrasound. We can see it apologised for the impact this had on Mr G. It set out service improvements, focussing on ultrasound techniques in similar clinical circumstances and ultrasound report writing.
30. The NHS Complaint Standards say NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people and identify suitable ways to put things right. It says NHS organisations should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned. They also say organisations should use learning to improve their services.
31. We have found the Organisation has done enough here. It acted in line with the requirements of the NHS Complaint Standards when it responded to Mr G’s complaint. Its acknowledgement of its mistakes and an apology for the impact they had on Mr G is a suitable remedy. And it has taken learning from his experience.
32. Mr G has asked us to consider recommending the Organisation pay him financial compensation. He has been clear service improvements are the driving factor in him considering this complaint resolved.
33. We do not think it is appropriate for us to recommend a financial remedy for this complaint. We have considered ‘Our guidance on financial remedy’ to inform our thinking. This says we would not usually recommend a financial remedy if the impact is annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wide impact.
34. We think this is an accurate reflection of Mr G’s impact. We acknowledge the worry he felt after the ultrasound he had in May 2024. We cannot see there were any other adverse effects or ongoing wide impact. Mr G did not require any treatment.
35. We have found the Organisation has acted in line with the NHS Complaint Standards when it responded to Mr G’s complaint. It has done enough to put things right for him.
36. We understand how important this complaint is to Mr G. We have found the Organisation made mistakes and we appreciate the impact they had on him. We are not upholding his complaint as we have found the Organisation has done enough to put things right for Mr G. This is not meant to undermine the issues Mr G asked us to look at. We hope we have fully explained how we have investigated this complaint.