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Screening Blunder 15/4/02

X-ray
"A wake up call for the the NHS" - that was how a health watchdog described the tragic failures at Hammersmith Hospitals NHS Trust that led to 11 breast cancer sufferers being told they had no symptoms.

The system, The Commission for Health Improvement said, was riddled with basic mix-ups and unaccountability.

But Newsnight can reveal that the breast cancer screening service was not the only disaster area.

There were, in fact, a number of inquiries into problems at Hammersmith Hospital's Radiology Department involving as many as 20,000 X rays and other scans which were rendered unusable by technology and managerial failures.

Our Health Correspondent Matthew Hill reported.

MATTHEW HILL:
To the public the Radiology Unit at the Hammersmith and Charing Cross Hospital Trust proclaims itself as a "flagship imaging department." It's not always been the case. The way crucial new technology was introduced there in the 1990s left thousands of patients without the diagnosis they needed. Staff who blew the whistle feel their concerns were not addressed and their careers suffered.

CHRISTINE ENGLAND:
I could never say to another person who might be in the NHS now, possibly watching this, thinking perhaps I should blow the whistle, I couldn't tell them go ahead and do it.

BILLY FLYNN:
If I was going to raise concerns, I would be careful to check I was going to get the support of senior people, and senior people within the Department of Health. And that is by no means certain.

HILL:
Radiologists are highly skilled hospital doctors. Their job is to spot minute abnormalities on scans which might be missed by junior hospital doctors looking after the patient. Their skills can be essential in diagnosing life-threatening conditions like cancers. Yet for much of the past ten years that expertise was denied to thousands of patients. In October 1993 the Hammersmith Imaging Department changed the way it processed the radiologists' analysis of an X-ray, known as a report, by introducing a new computer system called KRIS. A year later it also brought in a Philips Dictation System. Radiologists would examine a scan and record what it showed on the dictation system. Their diagnosis would then be stored on the dictation system for a secretary to transcribe later onto the KRIS computer. Ultimately the report would be archived in KRIS. While staff had experienced problems with the KRIS system on its own, these were compounded by the way the two systems were used together. There were no technical problems with the Philips system. Concerns about difficulties in reporting images were first raised by a senior medical secretary in the Radiology Department. This key whistle-blower who's invoked the public interest disclosure act has agreed to speak publicly for the first time.

ENGLAND:
The secretary would get a piece of dictation but wouldn't know who it belonged to. If you tried to check which patient it was, management would say you don't have time to check, you can guess by the date of birth. This was a reference to the way that the patients were entered into the Philips system. They were keyed in by the radiologist. They often made errors in keying in, so by that stage we had had nearly a year of two different systems with lots of problems which were leading to this combination of very high volume, hundreds if not thousands, of incomplete, inaccurate, severely delayed reports.

HILL:
Many scans were rendered unusable because reports were generated with missing characters and lines and even patients' names transposed.

ENGLAND:
Their doctor might have received a report with their name on top, but somebody else's report beneath it. The ones that worried me mainly were things like brain scans. People having maybe annual follow-up. The line might read "no recurrence" or "no residual tumour seen." Because of the system failures, that one phrase might be transposed from their report into someone else's.

HILL:
Many compromised reports were simply abandoned because it was impossible to identify who the patient was, Christine England says even reports which were identifiable were abandoned because staff were under time pressure.

ENGLAND:
Probably the abandoned ones, they potentially could be the most dangerous because patients generally don't hear from the doctor. They think it must be OK.

HILL:
In May 1995 Christine England was suspended by the Trust within two hours of putting all her concerns in writing. She says no reason was given by the hospital. But after her union, Unison, became involved, the trust maintained she was unable to cope with the workload, something Christine England vehemently denies.

ENGLAND:
They tried to transfer me to another hospital within the trust. I refused to take that transfer because I felt it would give the wrong signal to other staff.

HILL:
She felt she had no choice but to end her contract and is now working elsewhere in the NHS, leading a team of medical secretaries. At the time she left in 1995 the Trust became one of the first in the UK to pilot a new 10-million imaging system called PACS. It worked in conjunction with existing systems and was meant to give instant access to patient records and images from a range of tests. Terminals throughout both sites were to put an end to doctors trying to hunt down X-rays. Patients would be given their results more quickly. After two years the system was evaluated, just as it was about to be rolled out across the country. Experts from Brunel University found that while PACS had some benefits, there were two major drawbacks. It did not speed up the time it took from a patient having an X-ray to them getting their result and it did not improve the reporting service provided by the hospital's radiologists. Tucked away in one of the three volumes produced by Brunel is a sign that all was not as it should have been at the Hammersmith and Charing Cross Trust. On page 123, volume two, the report says, Approximately 30% of examinations were eventually archived unreported. That's over 20,000 examinations a year which never ended up with a final written and verified report. It says the PACS computer simply did not have enough storage space to cope with the backlog of images. Consequently those scans were unusable. It says, On more than one occasion the backlog of unreported images became so large that emergency deletion of unreported images took place. By this stage a number of senior doctors from the radiology department also had concerns about patient safety. One of them wrote this letter to the trust chairman warning that in September 1998 there were 11,600 unreported films on PACS. In November 1998, Christine England contacted the civil servant in charge of whistle-blowing at the Department of Health, in the hope that the problem could be solved internally.

FLYNN:
She said she was aware for a long time of unreported images, images being binned and various other stories of images going unreported. My immediate response was to verify what she had said. I spoke to one or two people who were put in touch with me by this lady and they confirmed that essentially her story was true.

HILL:
Were these senior people?

FLYNN:
These were senior people, yes.

HILL:
In fact several senior doctors had also voiced their concerns to Mr Flynn about the reporting system. He recommended the hospital set up an inquiry. The trust decided to make that internal and only to examine nine cases where patients had experienced long delays. We can reveal what it said. 10th July 1998. One brain damaged child had a scan which should have picked up a break in an artificial tube that drained fluid from its brain. Almost two months later the child was admitted as an emergency to Great Ormond Street Hospital. 16th July 1998. A scan was taken of a woman with breast cancer. It showed her condition was so advanced that tumours had spread to her spine. There was a delay before her doctor received the report. She therefore had to be admitted to casualty in severe pain. The report says, "The delay... put the patient at serious risk." The report concluded there had been delays in reporting some cases, though this had not resulted in any adverse effect upon patient health.

FLYNN:
I got a telephone call from two of the people who raised concern, who expressed their difficulty with the make up and terms of reference for the inquiry. One of the people who had been appointed to the internal investigation team was in effect going to be investigating herself. The whistle-blowers then said they would not co-operate with any further inquiry as they felt things were being brushed under the carpet. I rang the regional office and was told they were distancing themselves from the issue. In a sense they were washing their hands of it. It sent out a poor signal to the whistle-blowers who had raised this particular issue.

HILL:
Billy Flynn says the then Health Secretary, Frank Dobson, thought the first inquiry was a whitewash and ordered the trust to set up a second external investigation. It was carried out in March 1999 by Dr Mike Brindle. Newsnight can reveal just how limited its remit was. Dr Brindle "agreed to disregard evidence of past problems unless there was evidence such problems continued to present a hazard." The whistle-blowers regarded the report as another cover up and eventually Frank Dobson ordered a third inquiry. The report, by Ian Cameron from the University of Wales, was completed in June 2000. At the time Frank Dobson asked for this third inquiry it was understood that, like the Bristol heart scandal report, its findings would be made public. But to this day the report has never been published. When Health Secretary Alan Milburn's own inspectors from the Commission For Health Improvement asked him for a copy to help with their breast screening investigation, he refused to share it. The department say that is to honour confidentiality undertakings. Is it a cover up?

FLYNN:
I would not say yes or no, for the simple reason no one has seen the Cameron report. Until people do see the report they will make their own minds up about what happened and what didn't.

HILL:
Newsnight knows of at least one patient who slipped through the net. A scan was carried out on Joseph Spitari in February 1998, who had suspected cancer. It clearly showed a tumour on his right kidney, yet it took ten months after the examination was performed before the result was reported back to his doctor. I've spoken to a senior consultant here who tells me had action been taken immediately, Mr Spitari's life might have been saved. Professor Cameron summarised his findings in a letter to the then Health Minister, John Denham, in July 2000. While he was critical of the way Christine England's concerns had been handled, he did not conclude this amounted to victimisation. He did, however, recommend compensation be considered. She recently received compensation in five figures. Professor Cameron also wrote:
"With regard to the level of unreported images and delayed reports, I was in no doubt that patients were potentially at risk." And two internal hospital e-mails sent just over a year ago show the problem continuing. The first, on 22nd November 2000, says 800 patients records had been signed off as reported, even though they had not been. The second, from last February, shows that number had grown to 1800. No-one from the hospital has been available for interview. But in a statement they say since new management was brought in there are no delays in reporting images for urgent cases. As for thousands of unreported images we have uncovered, they say: "Little purpose is served by raking over events now in the past." But that might not be enough to satisfy the Commission for Health Improvement inspectors, who are about to carry out a wider review of the hospital.

KIRSTY WARK:
And in a further statement Hammersmith and Charring Cross Trust acknowledges there was a backlog of unreported images some years ago but that some of these were the result of multiple images being taken for one patient. They also cite severe staff shortages and point out that eight new consultant radiology posts have since been created.

This transcript was produced from the teletext subtitles that are generated live for Newsnight. It has been checked against the programme as broadcast, however Newsnight can accept no responsibility for any factual inaccuracies. We will be happy to correct serious errors.

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