A coroner has expressed concerns about medical scans not being followed up at a Cambridgeshire hospital. It follows as Richard Roe, 75, died in January 2023 after he was diagnosed with pancreatic cancer.
An investigation was conducted into Mr Roe’s death by Cambridgeshire and Peterborough coroner Simon Milburn later that month. It found that Mr Roe underwent a pulmonary angiogram at Hinchingbrooke Hospital in Huntingdon on September 26, 2021, revealing a pancreatic cyst.
Mr Roe underwent an subsequent CT scan on October 11, 2021, which identified a lesion in excess of 3cm in the tail of the pancreas. The reporting radiologist recommended that the scan be reviewed by the Hepato-Biliary MDT, but it was neither actioned nor viewed.
In a prevention of future deaths report published in December 2024, it was found that had the scan been viewed, it would have shown the presence of pancreatic cancer. Mr Roe went back to Hinchingbrooke Hospital in November 2022 and a subsequent CT scan revealed the presence of metastatic pancreatic cancer.
Mr Roe died at his home address on January 20, 2023. The report added that had his pancreatic cancer been identified in October 2021, it is likely he would have undergone surgery and been treated with subsequent chemotherapy.
The coroner acknowledged that although the chance of the treatment being curative was low, Mr Roe would not have died as soon as he did had it been provided. Mr Milburn said that there is a risk that future deaths could occur unless action is taken.
The evidence showed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians. The inquest heard that the Trust is investigating a new IT System which will be able to flag when such issues occur, but there is no current completion date known for the project and no system in place at present to prevent a repeat of such an incident.
North West Anglia NHS Foundation Trust published their response online. It said: “Reviewing scan reports appropriately and timeously has always been, and will remain, the primary responsibility of the clinicians who requested them and/or their departments. However, that failed for Mr Roe and we accept that there needs to be a system to ensure that routine scans aren’t overlooked which is dependent on individual clinicians or their departments.
“The Trust is in the process of improving its electronic records system so that it is comprehensive and includes all reports requested by clinicians including radiology reports. This is a substantial financial investment by the Trust both in terms of the technology and the staff time needed to implement it.
“The details of the system haven’t yet been finalised, but it will give the Trust more management and audit options and it is expected to include an easier ability to track the viewing of all types of reports, including those for routine radiology scans.
“However, as you noted, the implementation of the improved records system is some way off and as an interim measure, we’ve reviewed the abilities of the current radiology system and it can, and will, produce reports of unviewed scans (initially monthly) which can then be followed up with the requesting clinicians and/or their departments.
“The ability of the present system to provide information in detail is limited and at the moment it will identify a large number of unviewed images (most of which would be expected and not a concern) but in liaison with the external providers of the system we expect to be able to refine the information to better identify any scans that have been overlooked.”
The trust has been contacted for an additional statement on the report’s findings. Mr Roe’s family and legal representatives, as well as the Integrated Care Board and the chief coroner, received a copy of the report, which can be read in full here.
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