Doctor's errors examined after 101 patient deaths

Errors made by a doctor are being reviewed to establish whether they played a part in the deaths of 101 patients.

A former radiology consultant at Royal Derby Hospital has been under review, over cardiac MRI (magnetic resonance imaging) scans, since concerns were raised by cardiology colleagues in November 2020.

Documents seen by the Local Democracy Reporting Service (LDRS) showed 1,224 cases between 2013 and 2020, involving the doctor, were looked into as part of the review.

The University Hospitals of Derby and Burton NHS Foundation Trust claimed it took an "open and transparent" approach with the public in regards to the review and that "no significant harm" had been identified so far.

The initial review – due to be published in full later this year – found while there is an expected discrepancy rate of 5% for cardiac MRI scans, an audit of 63 cases found the doctor's discrepancy rate was 37%.

That meant it was seven times the accepted rate, presenting an error with one out of every three scans.

A discrepancy rate across the whole 1,224 cases has not been provided.

The ongoing review found that out of the 1,224 cases, two cases were found to show "definite omission or misinterpretation with unequivocal potential for serious morbidity or threat to life".

Of the cases reviewed, 102 were found to show "definite omission or interpretation of finding with strong likelihood of moderate morbidity but not threat to life".

Meanwhile, in 361 cases, "clinical significance of disagreement is debatable or likelihood of harm is low", and in 378 cases there was "disagreement over style and/or presentation of the report including failure to describe insignificant features".

A total of 176 patients out of the 1,224 assessed have now died, with a "misreported" cardio MRI scan found in 101 of those patients.

The medical examiner will now assess if any of the 101 deceased patient cases showed evidence that their misreported MRI, or any associated subsequent treatment delay, was "likely" to or "could" have "contributed to", "caused" or "accelerated" their deaths.

Affected patients were contacted by the trust.

A total of 120 patients had their cases recalled by the trust for further assessment with evidence of "misdiagnosis" "which will have impacted treatment decisions and pathways".

The hospital trust apologised for the impact on patients and indicated training and processes were at fault, but said changes had been made.

The review into the doctor was due to conclude in January, then believed to have then shifted to April and is still pending.

One affected patient, who was seen by the doctor in 2014, called the matter a "monumental failure to manage from trust leadership" and said the review had been badly handled.

She said she was notified about her misreported MRI nine years after the scan.

"We are not going to get the full picture because of how long it has taken. They haven't considered the future prognosis for patients.

"Nurses rely on diagnoses and care plans and there is potential care here that has not been given.

"This has taken away my choices. Because I didn't have that knowledge, I couldn't make decisions based on correct information and the people treating me couldn't make correct decisions either because of the misreporting of a scan.

"It is really, really upsetting."

Karen Reynolds, a clinical negligence lawyer at Freeths in Derby, who is representing the patient, added she was "shocked" the review had not come to light sooner.

"The trust must now be entirely transparent about this review," she said.

"It is their responsibility to uphold the duty of candour and do what they can to reassure patients."

The trust said the doctor had left the organisation, adding "no concerns have been found about the individual's other areas of practice".

The General Medial Council (GMC) - which regulated doctors - confirmed the doctor was still registered with a licence to practise with no restrictions.

No fitness to practise case has been brought before the Medical Practitioners Tribunal Service by the GMC, the MPTS confirmed.

The trust said those involved in reviewing the case at the time - which included colleagues external to the organisation - decided it did not meet GMC referral thresholds.

Dr Gis Robinson, the trust's executive chief medical officer, said: "We have re-seen and personally apologised to the 120 patients who have needed to be followed up as part of this review, and while so far the investigation has found no significant harm has been caused, we absolutely apologise again to those affected for the emotional impact this has had and for the extended time this has taken.

"Though scans are just one of many elements we use to diagnose a patient and variations in how clinicians read them are expected, our investigation has shown our processes were not as strong as they could have been and we have made changes – with scans now being reviewed as part of a multidisciplinary team, and a percentage of scans externally audited as an additional safety measure.

"Our priority has understandably been communicating with and supporting those who have been directly affected as we have moved through this process, and we will publish a public report as we normally would once the investigation in complete."

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