The Parliamentary and Health Service Ombudsman has called for ‘significant updates to guidance, working practices and digital capabilities’ in diagnostic imaging along the whole patient journey.
Ombudsman Rob Behrens’ report, Unlocking solutions in imaging: working together to learn from failings in the NHS, highlights failures to follow national guidelines on reporting unexpected imaging findings and to act on them, delays in reporting imaging findings, and failure to learn from past mistakes.
He said the problems related to the whole system and his recommendations had significant implications for all clinical professionals responsible for requesting imaging and acting on its findings.
These included the recognition that digital infrastructure should now be treated as a patient safety issue, and that there should be national guidance on the roles and responsibilities of clinicians, and expected timeframes, at each stage of the imaging journey, which should apply to referring clinicians of all specialties, as well as radiologists and radiographers.
There were three recommendations specifically for imaging services:
- All NHS-funded providers that have a radiology service should ensure staff working in those services have sufficient allocated time in their job plans for meaningful learning and reflection. NHS England and Improvement should have system oversight of this, working with RCR and SoR to identify how much job plan time should be allocated to learning and reflection per month.
- Clinical directors and senior managers of NHS-funded radiology services should triangulate the learning from across their departments on a regular basis. This should be no less than four times a year to identify systemic or recurring issues and share findings with staff in radiology services and other relevant departments.
- The RCR should review existing guidance on reporting unexpected findings and peer review of radiological reports to learn from the findings of the ombudsman’s casework.
Charlotte Beardmore, SoR director of professional policy, said the issues raised by the ombudsman were primarily a fault of the system rather than the workforce.
‘The demand upon imaging services continues to increase without significant investment. Chronic under-investment in imaging services has been continually raised by the Society at the highest levels with government bodies, and the workforce is under significant pressure with radiography staff shortages.
‘The Society of Radiographers welcomes the opportunity to work with government and all stakeholders to ensure that appropriate resources and structures are in place to support the workforce to deliver the highest quality care for patients and to respond to the recommendations within this report.
‘Years of under-investment will mean this is challenging as the workforce cannot be grown overnight. We believe that the College of Radiographers and the RCR Quality Standard for Imaging will provide a framework to support the changes provided there is significant investment in the workforce and imaging services.’