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Found 34 results
  1. Content Article
    In this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
  2. Content Article
    Katie Hurst is a general surgery registrar based in the Thames Valley Deanery and chair of the Trainees’ Committee for the Royal College of Surgeons of Edinburgh. In this interview, we talk to Katie about the work she is doing with the Royal College of Surgeons of Edinburgh on raising awareness and protecting staff from ionising radiation.
  3. News Article
    Patients are being exposed to radiation doses at the “upper limit of safe” because a hospital is relying on a radiology machine three years after its “end of life” with a substandard second-hand part. The risk was revealed in board papers from Medway Foundation Trust, in Kent, among several other serious problems linked to outdated equipment. Recent board papers said the machine was necessary for maintaining the trust’s interventional radiology service which includes being on-call 24/7. It said: “Owing to the age of the machine we are experiencing a growing number of faults and breakdowns and due to its age no new parts are available. “At present a second hand tube has been installed to replace the existing faulty equipment.” But the papers went on to say the second-hand part has a defect “causing serious issues with the imaging [which] has the potential to increase imaging acquisitions required which will increase patient radiation dose and lengthen the procedure time”. A business case for a new machine described current radiation doses as “within the upper limit of safe”. The trust indicated “mitigations” are in place, including additional reviews of patients who use it. Read full story (paywalled) Source: HSJ, 11 March 2024
  4. Content Article
    The Care Quality Commission's (CQC) annual report on their work to enforce the Ionising Radiation (Medical Exposure) Regulations in England has been published. The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about these. The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2022 and 31 March 2023. The report also presents the key findings from our inspection and enforcement activity in that time.
  5. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in radiology. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register
  6. News Article
    Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, May Ashford was not offered surgery until five years later. A woman died unnecessarily after doctors failed to operate soon enough on a growing brain tumour, according to the health complaints service. May Ashford, from Blackpool, was diagnosed with a brain tumour in 2010 after experiencing headaches and seizures. Despite regular MRI scans at the Royal Preston Hospital showing that the tumour was growing, she was not offered surgery until five years later. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) said the treatment was too late as medical staff had failed to monitor the scan results properly. Medical experts said Mrs Ashford should have been operated on at least three years earlier, before the tumour had time to grow and affect the surrounding area of the brain. She tragically died aged 71 from a stroke following surgery. Link to full article here
  7. News Article
    A new type of artificial-intelligence technology that cuts the time cancer patients must wait before starting radiotherapy is to be offered at cost price to all NHS trusts in England. It helps doctors calculate where to direct the therapeutic radiation beams, to kill cancerous cells while sparing as many healthy ones as possible. Researchers at Addenbrooke's Hospital trained the AI program with Microsoft. For each patient, doctors typically spend between 25 minutes and two hours working through about 100 scan cross-sections, carefully "contouring" or outlining bones and organs. But the AI program works two and a half times quicker, the researchers say. When treating the prostate gland, for example, medics want to avoid damage to the nearby bladder or rectum, which could leave patients with lifelong continence issues. Read full story Source: BBC News, 27 June 2023
  8. Content Article
    This letter from Dr Robert Farley, President of the Institute of Physics and Engineering in Medicine (IPEM) to Karen Reid, the Chief Executive Officer of NHS Education for Scotland (NES) highlights that lack of funding for Clinical Scientist training places is putting patient safety in Scotland at risk. Dr Farley says, "We understand NHS Education for Scotland are proposing funding that equates to less than a single training post in medical physics and clinical engineering in 2023. ‘This is despite the Scottish Government's Chief Healthcare Science Officer’s public acknowledgement of the importance of training. "Scotland currently has a 10 per cent Clinical Scientist vacancy rate across the medical physics specialisms. This equates to seven vacancies in radiotherapy, three in nuclear medicine, four in diagnostic radiology and radiation protection. These posts are critical to supporting diagnostics and cancer treatments."
  9. Content Article
    Exposure to ionising radiation during image guided procedures has been associated with a higher incidence of breast cancer in female healthcare workers. Lead or lead equivalent gowns are used to reduce radiation exposure during image guided procedures, but studies have shown that current gowns provide inadequate protection to breast tissue as they leave the upper outer quadrant and axilla exposed. Isobel Pilkington and colleagues discuss the risk and the steps that must be taken to ensure full protection of breast tissue in this BMJ Editorial.
  10. News Article
    The share of referrals waiting more than three months for a diagnostic test — one of the key problems behind long waits for cancer treatment — is worse than at any point since February 2021, during the second national covid lockdown. NHS England data released this morning for September shows 12.4% of the 1.6 million awaiting a test had been on the list longer than 13 weeks. At the peak of June 2020, 32% waited more than 13 weeks, but the proportion dropped back beneath 1 in 10, in May 2021, as services ramped up activity following the impact of the major winter 2020-21 Covid wave. Echocardiography patients and those needing endoscopies had the highest proportion of patients waiting more than six weeks – these specialties jointly comprise about a third of the total national waiting list and had 48 and 38%, respectively, of their lists over six weeks. Katharine Halliday, president of The Royal College of Radiologists, said: ”Today’s cancer waiting times data is alarming. We know the longer patients wait for a diagnosis or treatment, the less their chance of survival. “Our members are clinical radiologists and clinical oncologists, and much of their work involves diagnosing and treating cancer. Today’s figures show the NHS in England would have to employ 441 radiology consultants, the equivalent of a 16% increase in the current workforce, in order to clear the six-week wait for CT and MRI scans in one month.” Read full story (paywalled) Source: HSJ, 10 November 2022
  11. Content Article
    The need for radical investment and reform of diagnostic services was recognised at the time the NHS Long Term Plan was published in 2019. This report, commissioned by NHS England at that time, alongside a review of adult screening services, was nearing publication before the COVID-19 pandemic struck. However, while the recommendations made pre-pandemic still stand, additional actions will be needed to deliver safe, high quality diagnostic services in an endemic phase of the disease and to support the recovery of diagnostic services.
  12. Content Article
    This study in the International Journal of Radiation Oncology, Biology and Physics assesses the impact of the early Covid-19 pandemic on incident learning through evaluation of events reported to the Radiation Oncology Incident Learning System® (RO-ILS) in the USA. The authors conclude that reporting to RO-ILS declined during the early Covid-19 pandemic, especially in hotspot areas, suggesting that resources and time were diverted away from incident reporting to address other critical needs. However, three of the five top reporting practices that stopped reporting during early Covid have since reported events after the analysis timeframe, suggesting the decline may be temporary. 
  13. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  14. Content Article
    The Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk caused by delays in diagnosing lung cancer. Lung cancer is the third most common cancer diagnosed in England, but accounts for the most deaths. Two-thirds of patients with lung cancer are diagnosed at an advanced stage of the disease when curative treatment is no longer possible, a fact which is reflected in some of the lowest five-year survival rates in Europe. Chest X-ray is the first test used to assess for lung cancer, but about 20% of lung cancers will be missed on X-rays. This results in delayed diagnosis that will potentially affect a patient’s prognosis. The HSIB investigation reviewed the experience of a patient who saw their GP multiple times and had three chest X-rays where the possible cancer was not identified. This resulted in an eight-month delay in diagnosis and potentially limited the patient’s treatment options.
  15. Content Article
    Diagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.
  16. Content Article
    This report shares findings from complaints made to Parliamentary and Health Service Ombudsman (PHSO) about failings in imaging in the NHS. The majority of these complaints involve people who had cancer at the time they used imaging services. Through highlighting these complaints, the PHSO’s objective is to support NHS services to improve. It suggests that failings in imaging services can only be addressed and learned from through collaboration across clinical specialties, looking at the whole imaging journey and its intersections as part of the patient’s care pathway.
  17. Content Article
    This case study looks at how plastic cord clamps used in caesarean sections are not visible on x-ray, which could be a patient safety issue.
  18. Content Article
    This is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022. Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services.  The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services.   This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care.   Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care.   Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60.  We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs.   Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions.
  19. News Article
    A crisis in cancer care at NHS Tayside could have been averted if the health board had publicly supported doctors who were criticised by an official report, according to a top oncologist. The last remaining breast radiotherapy specialist left at the end of January, with the board unable to replace him. Patients must now travel to Aberdeen, Glasgow or Edinburgh for radiotherapy. The situation has emerged three years after an investigation into chemotherapy treatment at Ninewells Hospital. NHS Tayside apologised to patients in 2019 after an investigation found doctors deviated from national standards on chemotherapy dosages given to breast cancer patients after surgery. A subsequent review found that the lower dosages were highly unlikely to have led to the deaths of any patients. Last year the doctors involved were cleared of any wrongdoing by the General Medical Council (GMC), who also found no fault with the treatment patients received. Some clinicians close to those involved told BBC Scotland the cancer doctors felt they had no choice but to leave because they did not have the backing of the board. Colleagues who support the oncologists say none of this needed to happen. Prof Alastair Munro, emeritus professor of radiation oncology at Dundee University, who previously worked as a cancer doctor in the department, said: "It's a totally avoidable tragedy, this should not have happened. "The first thing the health board need to do is to come clean, and say we got it wrong, we put our hands up, we want to start again with a clean slate and we want to attract good people to come to Tayside to deliver breast cancer services to the patients whose needs we serve." Read full story Source: BBC News, 9 February 2022
  20. News Article
    A cervical cancer patient has been treated with the aid of artificial intelligence (AI) for the first time in the UK. Emma McCormick, 44, was treated at the St Luke's Cancer Centre in Guildford, Surrey. The Royal Surrey NHS Foundation Trust treated Ms McCormick, who is from West Sussex, using adaptive radiotherapy. The AI technology uses daily CT scans to target the specific areas that need radiotherapy. This helps to avoid damage to healthy tissue and limit side-effects, the hospital said. Patients are given treatments lasting between 20 and 25 minutes, although Ms McCormick's was slightly longer as she was the first patient, a hospital spokesman said. Ms McCormick received five AI-guided treatments per week for five weeks before having a further two weeks of brachytherapy. She said: "If it works for me, and they get information from me, it can help somebody else. It definitely worked and did what it was meant to do and so hopefully that helps others." Dr Alex Stewart, who treated Ms McCormick, said one of the benefits of the treatment was that it allowed for more precision, meaning there were fewer side-effects for the patients. Read full story Source: BBC News, 21 January 2022
  21. News Article
    About a third of NHS trusts in England are using “technically obsolete” imaging equipment that could be putting patients’ health at risk, while existing shortages of doctors who are qualified to diagnose and treat disease and injuries using medical imaging techniques could triple by 2030. According to data obtained through freedom of information requests by Channel 4’s Dispatches programme, 27.1% of trusts in NHS England have at least one computerised tomography (CT) scanner that is 10 years old or more, while 34.5% have at least one magnetic resonance imaging (MRI) scanner in the same category. These are used to diagnose various conditions including cancer, stroke and heart disease, detect damage to bones and internal organs, or guide further treatment. An NHS England report published last year recommended that all imaging equipment aged 10 years or older be replaced. Software upgrades may not be possible on older equipment, limiting its use, while older CT scanners may require higher radiation doses to deliver the same image, it said. Dr Julian Elford, a consultant radiologist and medical director at the Royal College of Radiologists (RCR), said: “CT and MRI machines start to become technically obsolete at 10 years. Older kit breaks down frequently, is slower, and produces poorer quality images, so upgrading is critical." “We don’t just need upgraded scanners, though; we need significantly more scanners in the first place. The [NHS England report] called for doubling the number of scanners – we firmly support that call, and recommend a government-funded programme for equipment replacement on an appropriate cycle so that radiologists can diagnose and treat their patients safely." Read full story Source: The Guardian, 18 October 2021
  22. News Article
    The Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020
  23. News Article
    A man who died from lung cancer might have been saved if a hospital trust had not "failed to act" on two abnormal chest X-rays, an investigation found. Growths identified in the patient's examinations were not followed up for three years and were then untreatable, the health ombudsman said. North Cumbria University Hospitals NHS Trust also failed to correctly handle a complaint from the man's daughter. The trust, which runs hospitals in Carlisle and Whitehaven, apologised. The investigation was carried out by the Parliamentary and Health Service Ombudsman (PHSO), which deals with unresolved NHS England complaints. The patient, referred to only as Mr C, was admitted twice to hospital with stroke-like symptoms in 2014 and 2015. On both occasions X-rays were carried out which found abnormal growths in his lungs, but no action was taken. In July 2017, Mr C was found to have advanced lung cancer and he died weeks later. Read full story Source: BBC News, 29 April 2021
  24. News Article
    A review of the work of a former locum consultant radiologist in the Northern Trust has identified major discrepancies in 66 images. The trust has concluded a review of 13,030 scans and x-rays. The review was launched in June after the General Medical Council raised concerns about the locum consultant radiologist's work. The highest level of hospital investigation will be carried out into the cases of 17 patients. More than 9,000 patients were contacted as part of the review. The review identified six images at level one - a major discrepancy where errors or omissions in reporting could have had an immediate and significant clinical impact for the patients concerned. A further 60 images were level two - a major discrepancy with a probable clinical impact. "Most of the images categorised as having Level 1 and Level 2 discrepancies are CT scans but some are MRI scans, chest x-rays and other x-rays," said the trust's medical director, Seamus O'Reilly. "That detailed clinical assessment, which has resulted in 69 patients being called back, was to determine whether any clinical harm occurred as a result of the discrepancies found in the lookback review," "I can confirm that following careful consideration, the clinical assessment group has determined that 17 patients should now be part of a Level 3 Serious Adverse Incident (SAI) review." Read full story Source: BBC News, 13 October 2021
  25. News Article
    A review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases. A full lookback review of 13,030 radiology images was launched last month. The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020. The review steering group chair said it was "images in levels one and two that we are most concerned about". "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director. "Most of these concern CT scans where inaccurate initial reading of the scans could, or is likely to, have had an impact on the patient's clinical treatment and outcome." More than 9,000 patients have been contacted as part of the review, which is looking at radiology images taken in Antrim Area, Causeway, Whiteabbey and Mid Ulster Hospitals as well as the Ballymena Health and Care Centre. Read full story Source: BBC News, 28 July 2021
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