Image of x-ray

Failures in communication or follow-up of unexpected significant radiological findings

Summary

The national investigation

X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk. 

The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients.


Reference event

In the investigation reference event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.


Investigation summary

This healthcare safety investigation reviews the processes for communication and follow-up of unexpected significant radiological findings to understand why such findings are not always received or acted upon.

The factors that influence the communication of results are explored and opportunities to reduce the risk of this happening in future are identified.

The investigation pays particular attention to unexpected significant radiological findings from chest X-rays performed during a patient’s time in an emergency department.

X-rays are the most common radiological examination and large volumes are requested from emergency departments. However, the conclusions of this investigation apply to the communication of radiological findings from other areas, and other types of diagnostic test results.