National Ombudsmen
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Man died after doctors missed opportunities to identify abnormalities on his X-ray

A 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray, an investigation by the Parliamentary and Health Service Ombudsman has revealed.

The investigation comes a year after a landmark report by the Ombudsman highlighted failings in how X-rays and scans are reported and followed up in the NHS.  

Mr B, who was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019, had been unwell for several days. He was admitted to hospital suffering from abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities.

The following day the man’s condition deteriorated. He suffered a heart attack and died. A PHSO investigation found the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life. 

Speaking on this case Ombudsman Rob Behrens yesterday said:  

“The case of Mr B highlights the devastating impact mistakes like this can have. If the Trust had picked up the abnormalities on his X-ray sooner, Mr B could still be with his family today. 

“As the NHS faces the challenge of rebuilding after the pandemic, it must not lose momentum in improving the way X-rays and scans are handled during a patient’s care.”  

The Ombudsman's report, Unlocking Solutions in Imaging: working together to learn from failings in the NHS, identified areas of concern including not only ignoring national guidelines when treating patients but also a culture of not learning from past mistakes. He said opportunities to spot serious health conditions earlier were being missed. 

Progress has been made by the NHS in implementing recommendations made by the Ombudsman in his report. These include improving digital reporting capabilities around X-rays and scans and the updating of guidance on the roles and responsibilities of clinicians. 

However, Rob Behrens has said more needs to be done to protect patients from serious harm. He yesterday said:  

“Attention and buy-in from the NHS’s senior leaders is crucial if we want to see sustained and meaningful change in how X-rays and scans are managed during a patient’s care. We need more collaboration across clinical specialties, looking at the whole patient journey once a scan has been carried out.

"I want to see the NHS treating complaints as a source of insight to drive improvements in patient care. Not learning from mistakes will mean missed opportunities to diagnose patients earlier. In the most serious cases, like that of Mr B, it will mean a death which should never have happened.”


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