Inquest hears about failure to review x-ray in asbestos-related death

2017 11 03 18 32 1799 Gavel 400

A coroner has criticized clinical staff at a U.K. hospital for failing to review an x-ray examination that might have led to an earlier cancer diagnosis for a patient who died from mesothelioma, a regional newspaper has reported.

An inquest held at Winchester Coroner's Court on 15 April was told that Maurice "Mo" Davison from Hartley Wintney in England died at home on 20 September 2020 from a cancer caused by asbestos exposure, according to an article in the Basingstoke Gazette.

Davison, an 83-year-old retired builder, was admitted to Basingstoke and North Hampshire Hospital in early 2020. An x-ray exam was carried out, but the scans were never reviewed ahead of his discharge, the report continued.

The main entrance of the Basingstoke and North Hampshire Hospital, southwest of London. Photo courtesy of Alamy.The main entrance of the Basingstoke and North Hampshire Hospital, southwest of London. Photo courtesy of Alamy.

"The problem came because the person who ordered the x-ray did not review it," said area coroner Rosamund Rhodes-Kemp, who referenced a report prepared for the Hampshire Hospitals NHS Foundation Trust (HHFT) that said the x-ray had not shown up as needing review on its paperless system, making the process "more challenging."

In response, an HHFT representative said that new computer servers were due to be introduced in March 2021 and that they should eradicate the problem, noted the Basingstoke Gazette.

Rhodes-Kemp said she would be contacting specialists at nearby Frimley Park Hospital for a second opinion, and she would also be requesting an update on the new IT system from the HHFT.

"I am going to take it up with Basingstoke [hospital] and make sure that either this new computer is in place, or ask what is in place to stop this happening again," she said. "I think everyone was doing their best for him (the patient) at Basingstoke, but the process needs to be tightened up so x-rays don't get missed."

Coroner's verdict

In May 2020, Davison received his cancer diagnosis after being urgently referred for scans at Frimley Park Hospital by his general practitioner, after he presented with weight loss and back pain, the Basingstoke Gazette reported. He was considered too frail for invasive management. But, at his request, he was able to remain at home with carers coming in twice a day.

"We know that Maurice would not have been able to come through it (therapy), but it could happen to someone else, where there's a chance that they could have treatment," Jeanette Burton, a close friend of the patient, told the inquest.

The coroner recorded a verdict of industrial disease.

"The sad reality is it (the missed x-ray) made very little difference because of the progress of his condition. It may not have impacted on Mo's life expectancy, but x-rays do need to be reported and reviewed," she said.

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