A man may have lived longer if vital scan results had not been left on a desk for six days, a coroner has found.
Retired HGV driver Trevor Reynolds, 79, was receiving treatment for cancer of the oesophagus at Glen Clwyd Hospital in Wales when the radiologist conducting a CT scan on 3 May 2021 noticed a blood clot. The discovery should have prompted urgent treatment, Mr Reynolds’ consultant said. However, although he discussed the scan with Mr Reynolds on 6 May, he had not seen the results, since they had not been entered onto the hospital system. Instead, the results were placed on the consultant’s desk, but because he was out of the office and on leave for the next six days, no action was taken.
When an occupational therapist made a home visit, they noted Mr Reynolds’ worsening condition and alerted his GP, who arranged a hospital admission. The hospital began treating Mr Reynolds, but he sadly died on 15 May 2021. A post -mortem examination was undertaken by Dr Mark Atkinson who provided a cause of death of pneumonia and pulmonary embolism due to deep-vein thrombosis on the background of emphysema and cancer of the oesophagus.
In his ruling, the coroner, John Gittins, noted that earlier treatment for the clot would have increased the chances of success. It was therefore more likely than not that Mr Reynolds would not have died if timely action had followed the scan result.
Mr Gittins said:
“On the 3rd of May 2021, Mr Trevor Reynolds had a CT scan at Glan Clwyd Hospital, the purpose of which was to establish the effectiveness of treatment which he had been having for cancer of the oesophagus.”
On the 6th of May this was reported by a radiologist as incidentally revealing a clot on the lungs, a result which needed to be brought to the immediate attention of the referring clinician so that remedial work could be started.
For reasons associated with working practices at that time the result of this scan was not acted upon until it was identified by Mr Reynolds’ GP on the 10th of May and he was immediately admitted to hospital where treatment was commenced.
Despite appropriate treatment being undertaken over the course of the next few days, Mr Reynolds passed away at Glan Clwyd Hospital on the 15th of May 2021 with a subsequent examination establishing that he had died as a result of both the pulmonary emboli and a pneumonia.”
“The evidence indicated that had treatment for the clot began sooner there would have been a better prospect of it being successful and further that the treatment of his cancer had been effective.
“On the balance of probabilities therefore it is likely that Mr Reynolds would not have died on the 15th of May 2021 if the result of his scan had been acted upon when reported by the radiologist on the 6th of May.”
The costs of human error
CT scans — or computerised axial tomography — provide three-dimensional imaging and are used to diagnose illness and assess treatment. The NHS performs nearly half-a-million CT scans a month. The detail they provide means they can often spot problems long before a patient has any symptoms, enabling prompt and effective treatment.
Unfortunately, in Mr Reynolds’ case, the process failed, with a hard copy of the results left unseen despite the consultant being on a planned absence.
The hospital acknowledged weaknesses and has improved their procedures. However, the coroner criticised the hospital for what he saw as a tardy response. The new processes to ensure an appropriate consultant sees urgent results promptly were not formally adopted until December 2021, seven months after Mr Reynolds’ death.
Mr Gittins expressed further disbelief that an audit of the new system to ensure that it was working as intended did not begin until five months later, rather than being part of the implementation process.
Technology plays a bigger and bigger role in medicine. There are over 40 million imaging tests a year in the NHS, including everything from X-rays to full-body MRI scans. However, the technology needs to be backed up with systems and checks that ensure the results are acted upon, and human errors — like leaving scans at an unattended desk — are avoided.
Compensation for the late diagnosis of a blood clot or deep vein thrombosis
If your blood clot was not diagnosed correctly or there was a delay in reviewing your scan results you could be entitled to claim compensation for hospital negligence or delays diagnosis.
Our solicitors are sensitive, compassionate, and will fully support you throughout the claims process. For more information on Devonshires Claims ‘No Win No Fee’ blood clot misdiagnosis service contact us today on 0333 900 8787, email admin@devonshiresclaims.co.uk or complete our online contact form.
