Scan report by Staffordshire Combined Trust
20. We have found two guidelines that were in place at the time of the events complained about that explain what should have happened. The guidelines for radiology can be found in BFCR (10)5 from the Royal College of Radiologists (the RCR guidance).
21. The doctor requesting the scan should have followed the guideline found in the National Patient Safety Agency Safer Practice Notice 16: Early identification of failure to act on radiological imaging reports (the NPSA guidance).
22. The RCR guidance says it is the role of the radiologist to ensure that scan findings are reported and verified. It goes on to say: ‘It is the responsibility of the referring healthcare professional to view, act upon and record the results of imaging studies that are requested’.
23. We have seen the RCR guidance was followed by the radiologist at UHNMT, as the finding of evidence of a historic stroke was reported to the clinician that requested the CT scan, Dr C at Staffordshire Combined Trust.
24. The NPSA guidelines say the referring registered health professional should: ‘Inform patients of all results, positive or negative, and document that this has been done. A standard letter to patients could be an additional safety mechanism’. It goes on to say that Trusts should: ‘Define and document ‘safety net’ procedures, for example, copy reports to the GP, cancer services multidisciplinary team or other identified health professional in consultation with the referring health professional’.
25. However, the requesting doctor at Staffordshire Combined Trust did not: ‘act upon the report findings’. The NPSA guidance was not followed. Ms N was not told of the finding, and there was no safety-netting in the form of arrangements being made to convey the information to her GP.
26. We find Staffordshire Combined Trust did not follow the guidance we have identified. Staffordshire Combined Trust should have made Ms N aware of the incidental finding of stroke in 2015. This did not happen. We consider this is a failing by Staffordshire Combined Trust.
Treatment provided by UHNMT
27. Ms N says being told by UHNMT in 2017 she had previously suffered a stroke caused her significant distress. This was made worse when she was told this had been identified by the CT scan two years earlier, and she had not been told at that time.
28. Ms N says that in addition to the distress this caused her, she also believes that the failure to tell her about the stroke finding means that she was not started on medication when she should have been, and that this has contributed to other medical conditions, in particular calcification of a heart valve and tinnitus.
29. We sought further advice from our stroke adviser. Our stroke adviser agreed Staffordshire Combined Trust should have told Ms N about the signs of stroke in the CT scan. Our stroke adviser also said that starting steps to prevent secondary events (secondary preventative measures) would have been appropriate at that time.
30. However, our stroke adviser explained it is not a prescriptive process. Either a GP or a more specialist physician could arrange and begin the secondary preventative measures. Either way, Staffordshire Combined Trust should have made the GP aware of the incidental finding and advised them to arrange secondary prevention advice and perhaps a referral to the stroke clinic.
31. We consider it likely Ms N would have received the same precautionary treatment as suggested in NICE guidance (https://cks.nice.org.uk/stroke-and-tia#!scenario:2). This is something acknowledged by UHNMT in a letter to Ms N.
32. In her complaint to us, Ms N said she was very concerned that the delay to starting preventative treatment put her at risk. In the response to her compliant, UHNMT said the greatest risk of reoccurrence of strokes is in the first four weeks following a stroke. It suggested that by the time the scan took place in 2015 the point of greatest risk had already passed.
33. Our stroke adviser explained the results of the 2015 scan indicated that the stroke had likely occurred weeks if not years previously. As such the immediate risks of another stroke were less than they would be had the stroke just occurred.
34. It appears the response references a statistical quote from the Stroke Association. In Stroke Statistics 2015 it says in the preamble: ‘the greatest risk of recurrent stroke is in the first 30 days’. However, our stroke adviser explained stroke reoccurrence is variable and dependent upon risk factors. This is why it is important for secondary prevention and review by a clinical team specifically interested in this issue, either GP, or stroke clinic, to take place.
35. Our stroke adviser said in addition, there is a cumulative risk of stroke reoccurrence over a longer period (Risk and Cumulative Risk of Stroke Recurrence, Stroke 2011;42;1489-1494), although they did note that Ms N’s risk factors were small.
36. Our stroke adviser said it is unlikely that starting precautionary medications in 2015 would have prevented Ms N developing tinnitus. Our stroke adviser also said that while they cannot say for certain, it is unlikely that the calcification of the heart valve that Ms N has developed is linked to any delay in either reporting the findings or in beginning secondary preventative measures.
37. We find UHNMT had no reason to make Ms N aware of the findings of the CT scan until 2017. We also consider UHNMT provided Ms N with a fair and reasonable response to her concerns.
38. We find Staffordshire Combined Trust failed to take the correct steps following the finding of the 2015 scan. It should have made Ms N aware of the incidental finding of stroke in 2015. We consider this caused distress to Ms N when she became aware of this finding in 2017. Staffordshire Combined Trust has not yet taken any steps to acknowledge this, or to put it right. Based on this, we consider there is a failing by Staffordshire Combined Trust that has led to an injustice that is yet to be put right.
39. We also believe Ms N would likely have started further treatment had the findings of the 2015 scan be acted upon. However, we do not consider there is evidence to say this led to any negative clinical impact on her, and therefore this has not directly caused an injustice.
40. We do not see evidence of failings by UHNMT. Therefore, we do not uphold this part of the complaint.