Safety recommendation
It is recommended that the Royal College of Radiologists, working with the Society and College of Radiographers and other relevant specialties through the Academy of Royal Medical Colleges, develops:
- principles upon which findings should be reported as ‘unexpected significant’, ‘critical’ and ‘urgent’
- a simplified national framework for the coding of alerts on radiology reports
- a list of conditions for which an alert should always be triggered, where appropriate and feasible to do so.
Response:
We extend our sympathy to the family of the patient at the heart of these systemic failings and welcome the thorough investigation of the wider issues raised in the reference case to this investigation.
As the report points out, there have been a number of attempts to resolve the challenges of alerts and acknowledgments of unexpected findings over the years, especially since in 2007 the National Patient Safety Agency (NPSA) Safer Practice Notice highlighted the risk of harm to patients if radiology reports are not acted upon.
Ownership of alerts and acknowledgements extends between teams.
After very positive initial discussions with the College of Radiographers and the Academy of Medical Royal Colleges, we are committed to gathering data and evidence to inform conditions which should always be notified by the end of December 2019. Through the Academy we will consult widely across specialties to establish consensus on those conditions and identify the key partners with whom we will work to develop principles for classification and national model for coding. We intend to publish substantive guidelines in Autumn/Winter 2020.
Whilst convergence in terminology and methodology on significant unexpected findings will make considerable progress toward avoiding these critical diagnoses falling between the gaps, the value of this safeguarding is limited without digital systems and infrastructure capable of adapting to an agreed national framework. This is particularly important as we move toward an increasingly networked approach to delivery of our diagnostic services, which will challenge systems and the integration between teams and organisations. We have invited NHSX to join us to ensure that the collaborative framework we develop can be practically implemented across the country at the earliest opportunity. This is the key lever to ensure that both patients and services can have confidence that serious unexpected findings will be acted upon.
Response received on 10 October 2019.