Patient death and “lasting, real harm” caused to over 100 people due to poor reading of heart scans

Royal Derby Hospital. Photo by Eddie Bisknell.

A patient died and “lasting, real harm” was caused to more than 100 people due to poor reading of heart scans by a former Derby doctor over seven years.

On top of this, more than 361 patients encountered potential low harm and a further 379 patients faced failures over their cardiac scans.

The University Hospitals of Derby and Burton NHS Foundation Trust has issued an “unreserved apology” for the issues, detailing “deep regret” and saying it is “very sorry this has happened”, pointing to an absence of oversight and its own policy shortfalls.

Its report, which was due to be published last year, has now been disclosed ahead of a trust board meeting next week.

This comes a year after the Local Democracy Reporting Service exclusively revealed that a review of 1,224 cases linked to one radiologist was under way, including medical examiner deep-dives into whether failures over cardiac MRI scans had played a part in the deaths of 101 patients.

This wide review includes the “potential misdiagnoses or delay in diagnosis” for hundreds of patients over seven years.

The radiologist in question has not been named and had already left the trust as of last July. He could not be reached for comment.

The Derby and Burton hospital trust’s full report confirms that one of the patients in the review, who has since died, suffered “severe harm” due to the missed diagnosis of a heart condition.

This, the trust says, was linked to the misreporting of a cardiac scan, which contributed to their health subsequently deteriorating until their death.

The report says a key theme of misdiagnosis was cases related to ARVC (arrhythmogenic right ventricular cardiomyopathy), which require annual checkup scans, genetic testing and family screening, which will not have been carried out, with potentially affected relatives going unassessed.

Another theme was patients having a diagnosis changed from myocarditis to myocardial infarction and vice versa, the report said.

A total of 176 patients in the 1,224-case review had died as of the investigation starting, with the medical examiner asked to assess 101 of these cases to see if the cardiac MRI had played a part in their deaths.

In these 101 cases, the trust states it was not able to assess other ailments which may have been caused by the misreporting of the heart scans or possible other health impacts or limitations on quality of life caused by the heart conditions that could have been treated via accurate scans.

Of those 101 cases, 48 had a “potential cardiac cause of death”, with three of those cases showing “possible influence” on the death of patients.

In eight cases there was “insufficient data” to reach a conclusion, including insufficient clinical notes, with the “circumstances of death not clear”.

Following this, a further post-mortem took place into the three cases, finding “possible influence”, with officials saying two patients suffered no harm as a result of the MRI discrepancy, but that one patient did suffer severe harm due to the missed diagnosis.

As part of the 1,224-case review, 120 patients were recalled for further investigations.

The trust said three patients were proven to have suffered “moderate harm”, while others suffered “real harm” which “may be lasting”.

Its report details that of the 120 patients, 48 recalled were found to have suffered low harm.

The trust writes: “It is not clear from the available documentation whether potential delays to diagnosis were fully reflected in the harm grading.”

Outside of the recalled patients, the trust refers to 36 cases audited by its officials, which found moderate and low risks of harm caused by “omission or [mis]interpretation” of MRI scans.

The trust confirms that it has only assessed physical harm and not considered psychological harm, including the mental health impact of a misdiagnosis or significantly delayed diagnosis.

It details: “Psychological harm was not considered as part of the review, but a degree of harm should have been presumed given the potential delay in diagnosis this could have caused, and the trust accepts that it should have ensured any patients that needed it had access to counselling, or other supportive wellbeing services and support.”

Aside from the 120 recalled patients, independent consultants assessed the whole batch of 1,224 patients.

The trust details that two patients had been categorised as category one, meaning there was a “definite omission or misinterpretation with unequivocal potential for serious morbidity or threat to life”.

Meanwhile,  there were 102 category two patients who encountered a “definite omission or interpretation of finding with strong likelihood of moderate morbidity but not threat to life”.

A total of 361 patients were placed in category three, where “clinical significance of disagreement is debatable or likelihood of harm is low”, and 378 patients were assessed as category four, where there was “disagreement over style and/or presentation of the report including failure to describe clinically insignificant features”.

It said in its new report that “some” of the recalled patients required further tests, treatment and follow-ups as a result of the review and in a “small” number of recall appointments, “patients were not given a clear explanation at the time as they should have been”.

As part of the report, the trust writes: “The trust unreservedly apologises to all patients who have been affected, and has taken actions to ensure, as far as possible, that this could not happen again.”

The trust said concerns were raised with it by colleagues of the unnamed radiologist in November 2020, with a December sample audit of 28 cases finding a much higher number of discrepancies than the expected rate.

That audit found four cases (14 per cent) of a category two concern, detailing definite omission or interpretation with a strong likelihood of moderate harm but not threat to life, and 15 cases (54 per cent) of category three discrepancy, finding minor issues and low risk of harm.

A second audit of 35 further cases found six (17 per cent) category two cases and 11 (31 per cent) category three issues.

These, the trust said, “were high and added to the clinical concern, especially in this high-risk group of patients”.

It says cardiac MRIs are now routinely assessed by a number of cardiologists working together in a team, improving oversight.

The trust details in its report: “We recognise that reading about this review may be worrying or upsetting, particularly if you or a loved one had a cardiac MRI scan at our trust during the period covered.

“We also recognise that, for some people, this review relates to real harm, and that the impact may be lasting.

“We want to be clear and open about what happened, how it was identified, what we have done to put things right, and what we have learned.

“We have taken this extremely seriously from the outset, and we would like to offer our sincere and unreserved apology to every patient and family affected.

“It is recognised that in diagnostic imaging there will always be some level of variation between reports, particularly for complex specialist tests.

“However, the pattern and level of discrepancy identified needed further investigation and action.

“The consultant concerned was a trained specialist and the nature of our investigation speaks to the wider systems issues and identified learning so that we can improve patient care.

“Most patients that were part of this review were not harmed, or experienced only a low level of harm.

“However, three patients were found to have experienced moderate harm and, very sadly, one patient experienced severe harm.

“We are truly sorry for the impact this has had on those affected.”

Dr Gis Robinson, the trust’s executive chief medical officer, said: “We are deeply sorry to the patients and families affected by the findings of this review.

“While the review found that most patients did not experience harm, we recognise that, sadly, this was not the case for everyone and we offer our sincere and unreserved apology for the distress and harm caused.

“We have taken this extremely seriously, been open with those affected, and have made significant changes to how cardiac MRI scans are reviewed, including ensuring scans are routinely discussed by teams of specialists rather than individuals working alone, alongside additional independent checks and audits.

“We are committed to learning from what happened and to ensuring these improvements lead to safer care and better outcomes for our patients.”

The trust asks that patients with concerns contact it through its Patient Advice and Liaison Service (PALS), at: uhdb.contactpalsderby @ nhs.net; telephone 01332 785156; or by text 07799 337 500. A voicemail can be left outside of opening hours.