Patients being harmed due to repeated mistakes in reading scans

Repeated failings in the way scans are read are leading to delays in cancer diagnosis, unnecessary operations and avoidable deaths, England’s Health Ombudsman has warned.

Since publishing a report four years ago which highlighted mistakes in the way digital images are read and used as a diagnostic tool, the Parliamentary and Health Service Ombudsman (PHSO) has upheld or partly upheld more than 40 cases in which similar failings were found.

The most common issues are doctors failing to identify an abnormality, scans not being carried out or delayed, and results not being properly followed up.

Examples of the impact of these failings include a 10-month delay in cancer being diagnosed which significantly harmed the person’s chance of survival. In another case, serious pelvic sepsis was not identified which led to an avoidable death, and in a separate case, a missed ankle fracture led to an avoidable operation.

The Ombudsman is calling for greater learning when things have gone wrong to prevent the same mistake being made.

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Source: PHSO, 20 March 2025