Investigation finds diagnostic delay caused patient's death

2020 09 29 18 15 5771 Medical Error 400

A serious incident report issued by a U.K. hospital group has found that the root cause of a woman's death in May 2020 was a delay in diagnosing her lung cancer following the results of a CT scan, according to an article posted on 3 February by the Slough Observer.

After being diagnosed with pneumonia and possible chronic obstructive pulmonary disease in January 2018, Irene Ellingham underwent two CT scans while she was a patient in the Parkside Suite, a private ward based at Slough's Wexham Park Hospital, which is run by Frimley Health National Health Service (NHS) Foundation Trust, the article stated.

The scan results were abnormal, but instead of sending the patient to a lung cancer specialist under the NHS' urgent two-week cancer referral, a private radiologist incorrectly recommended that she undergo a follow-up chest x-ray in four to six months' time. The exam was never booked, the Slough Observer report noted. The 74-year-old patient was diagnosed with cancer, which had spread to her liver and bones, in May 2020, and later she died at home.

The serious incident report from Frimley Health NHS Foundation Trust recommended the referral processes for private patients at the hospital are aligned with the steps taken for NHS services.

"The hospital trust's review has identified worrying areas in the private healthcare Irene faced," said Millie Bolsover, the legal expert at Irwin Mitchell, the medical negligence legal firm that represented the patient's family. "We hope that health professionals learn lessons from the issues that the trust has identified and are reminded of the need of working closely with the NHS to improve patient care."

A second article on this incident appeared in the local media on 9 February that included a response from the Frimley Health NHS Trust.

"We have conducted a thorough investigation into Mrs Ellingham’s care, and we have shared and discussed our findings with her family," a spokeswoman told the Maidenhead Advertiser.

"We again offer them our sincere condolences and we will continue to keep them informed of any developments, including any actions taken following our review," she said. "As legal proceedings are ongoing it would be inappropriate for us to comment further."

The serious incident report states that there should have been a "high degree of suspicion" that the patient had lung cancer following the scans in 2018, according to the Maidenhead Advertiser.

The investigation found that the radiologist who conducted the scans did not specialize in chest imaging, and the report stated that the failure to refer the patient to a lung cancer specialist following the scan was a "missed opportunity" to diagnose her condition, it added.

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