"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.
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.
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
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.
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
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.
Many scans were rendered unusable
because reports were generated with
missing characters and lines and even
patients' names transposed.
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.
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
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
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.
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
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.
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.
Were these senior people?
These were senior people, yes.
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
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.
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
Is it a cover up?
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
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.
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.