PATIENTS may have been “worried unnecessarily” by Health’s handling of concerns about the Radiology Department, a member of the Health Advisory Board has claimed.
Professor Dame Clare Gerada – former president of the Royal College of General Practitioners – said she was “perplexed” by data emerging from the examination of mistakes made in interpreting mammography scans, which she said showed that the errors fell within accepted parameters for the interpretation of imaging by radiologists.
And it has emerged that the decision by Health to review and recall some patients following their mammography scans was taken in spite of the fact that a formal review conducted by the British Society of Breast Radiology judged it unnecessary.
HCS defended its decision in a report presented this week to the Health Advisory Board, saying that the five-month delay that affected patients was “a relatively long period of time, and the HCS view was that it was not acceptable that… these patients [were allowed] to simply return as normal over the [following] few months”.
The department acknowledged NHS National Quality Board guidance on patient-recalls which said that patients may be “anxious during the recall process” but added: “It is important to note that our communication plan was to ensure that if any Jersey patient was concerned about their mammogram and they had not heard from HCS at the time of the public announcement, they could be reassured that this issue did not affect them.
“Once all the relevant patients had been contacted – in the interests of transparency and reassurance – HCS then briefed the media and facilitated interviews with both the minister and the deputy medical director.”
But at this week’s board meeting, Dame Clare said “there was a risk of worrying patients unnecessarily”.
“There are things that need to be put into the context of normality,” she said.
HCS has not published the full text of the BSBR report but extracts appeared in the board meeting paperwork.
The BSBR found six cases which warranted a duty-of-candour discussion – the obligation to be open and honest when something has gone wrong.
But while it said that “there [was] no suggestion of poor performance by other members of the breast imaging team”, it also noted that “in most of these cases, either more than one individual or the MDT as a whole was responsible for the delay in diagnosis”.
The report highlighted “lack of action” when issues were repeatedly raised, and HCS acknowledged that concerns had been raised over the previous three years but had not been escalated to the medical director or to senior management because of “a failure, or lack of, governance structures [which] led to a retrievable discrepancy being left for three years”.
The BSBR report states: “This resulted in considerable mental stress on those raising concerns, which could have been avoided.
The delay in action has also had an impact on the radiologist and the general functioning of the unit, as the loss of confidence in him and governance of the unit could have been minimised if the issues had been addressed promptly. We believe this is now irredeemable. The above scenario appears to be symptomatic of a wider lack of management and inadequate communication.”
