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400 Patients Misdiagnosed at Four Greater Manchester Hospitals

Following an urgent internal procedural review, a hospital trust in North West England has discovered that 400 patients were misdiagnosed.

Pennine Acute NHS Trust

Pennine Acute NHS Trust runs Fairfield General (Bury), Rochdale Infirmary, North Manchester General and Royal Oldham. The trust’s review of complaints and incidents over the past 5 years, relating to missed diagnoses, was carried out following an increase in the number of failings reported by medical staff.

Health chiefs at Pennine Acute NHS Trust found that there had been a possible delay in diagnosis or treatment of cancer in 105 of the cases reviewed.

Out of the 400 cases, 20 were also classed as ‘serious incidents’ – 14 of which resulted in ‘severe harm’ to the patients.

The trust is currently reviewing scans and X-rays from all four hospitals and this is an on-going process.

The probe has been deemed ‘significant’ by health watchdog the Care Quality Commission (CQC) and a spokeswoman for the watchdog has stated that they are ‘closely monitoring’ the review.

Report

According to a Trust report obtained by the Manchester Evening News (M.E.N), 11 serious incidents in the Trust regarding misdiagnosis were reported by staff between April and August 2015. The report also reveals that Clinical Commissioning Groups have identified a further 27 serious incidents, whereas between January 2010 and March 2015, just five serious incidents were reported by staff.

The report says:

“In response to the concerns raised within the Trust and shared by partners, the Trust undertook a five year review of Trust incidents and complaints of the most common areas relating to missed diagnoses.”

Incidents & Complaints between 2010 & 2015

In total 1,635 incidents that occurred within the last five years were identified by the report – 398 of such incidents required further review. 105 of those cases subjected to further review were identified as possible delay in treatment or diagnosis of cancer; 280 related to blood clots and 13 were potential missed fractures.

78 of the 105 were again subjected to further scrutiny – twenty of which were determined to be ‘serious incidents’, four were considered to have caused the patient ‘moderate harm’ & 14 were recorded as causing ‘severe harm’.

The review also highlighted the 56 complaints recorded between 2010 and April 2015.

As a result of the probe, a specialist team will now review further the case notes of 106 incidents & complaints highlighted within the document. According to the report, the specialist team will include a specialist nurse and a member of the clinical audit team, as well as the deputy medical director, Roger Prudham.

‘Patient safety and the quality of care we provide is our top priority’

According to hospital bosses however, the review is part of a ‘continual improvement plan for diagnostic tests’.

A spokesman for Pennine Acute NHS Trust has said:

“Patient safety and the quality of care we provide to our patients is our top priority.

“The nature of healthcare means the Board and our staff are committed to promoting continual learning and improved clinical practice in line with national guidance and best practice.

“As part of the Trust’s quality improvement work and safety programmes, which are aligned to the national NHS Sign Up to Safety initiative, our doctors and nursing staff are focusing on a number of areas to improve patient safety and patient experience to become a truly quality-driven provider of healthcare.

“Our safety priorities for this year focus on reducing avoidable harm to patients, particularly around hospital inpatient falls, sepsis, pressure ulcers, infection prevention, safer surgery and diagnostics such as radiology, X-rays and CT scans.

“As we strengthen our governance processes and incident reporting, we have seen an increase in the number of our clinical staff coming forward to highlight areas where we can make care safer and ensure we are doing all that we can to provide high quality care.

“Our work on diagnostics has involved looking at our clinical processes, policies and practice around x-rays and CT scans. This is to ensure that these tests for our patients are undertaken promptly and the reports are received by the appropriate healthcare professional so that diagnosis and necessary treatment can commence.

“As part of this improvement work, we have looked at the data on our incident management system over the past five years related to diagnostics to ensure that we can capture all learning from past cases in the improvement work we are doing.

“There is no data available or evidence to suggest the Trust is an outlier in this area.”

Care Quality Commission

A CQC spokesperson said:

“CQC is aware of the quality improvement work that Pennine Acute Hospitals NHS Trust that is undertaking looking at incidents and complaints related to diagnostic tests from the last five years.

“As the quality and safety of service provided to patients is paramount, we are in contact with the trust and are closely monitoring the progress of this work. Once concluded we will then determine what, if any regulatory action should be taken.

“Where a review of a service or system indicated shortfalls, delays or patient harm we would expect a trust to investigate these issues thoroughly and take action to meet its obligations in accordance with the Duty of Candour.”

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