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Woman’s avoidable death shows urgent need for improvements to NHS imaging, warns health Ombudsman

A woman died from an operable brain tumour after doctors failed to properly monitor her scan results, an investigation by the Parliamentary and Health Service Ombudsman (PHSO) has found.

May Ashford, who lived near Blackpool, was diagnosed with a brain tumour in 2010 at the Royal Preston Hospital after experiencing headaches and seizures. Despite regular MRI scans showing the tumour was growing and was pushing her brain to one side, she was told that it was not growing and was not offered surgery to remove it until May 2015.

PHSO’s investigation found May was not offered surgery until it was too late as medical staff failed to monitor the scan results properly and did not report significant findings.

Independent medical specialists told the Ombudsman that May should have been offered surgery three years earlier. As the tumour grew and affected the surrounding area of the brain, the more likely it was that May could be injured or die following surgery. Tragically, May died from a stroke in 2015 after her surgery.

Ombudsman Rob Behrens said this case once again emphasises the need for urgent improvements to imaging practices in the NHS:

“This tragic case highlights why we have been calling for imaging improvements to be treated as an urgent issue of patient safety. Our casework shows that sadly, Mrs Ashford is not the only person who lost her life because of mistakes related to scans and X-rays.

“Timely analysis and reporting of scans is fundamental to the diagnosis and management of many health conditions. The sooner we see changes made; the fewer people we will see harmed by these entirely avoidable failings.”

May’s husband Alan brought a complaint to the Ombudsman as he had concerns about his wife’s care. He said:

“Thanks to the Ombudsman’s meticulous report, new rules regarding the monitoring of patients have been implemented by the hospital to ensure that this cannot happen again to anyone else. My wife suffered horribly from the effects of the tumour for more than four years, and it was obvious to the family and myself when reading the scan reports that the monitoring of her tumour was highly suspect.

“The tumour should have been removed before it came into contact with the carotid artery. The fact that it was not is a complete mystery to us. We have no idea why the consultant concerned acted in the way that they did, and as we have never been offered an explanation, we have no closure.”

The Ombudsman’s 2021 report on NHS imaging highlighted repeated failings like those found in May’s case. PHSO led a call, alongside NHS England and the Royal College of Radiologists, to urge the Government to prioritise improvements to the way scans and X-rays are carried out and reported on. Since then, a collaborative effort across the NHS to implement the Ombudsman’s recommendations has begun, but progress has been slow. As this case highlights, this essential work must be prioritised to make sure patients are protected from harm.

Read the case summary.


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