A patient died as a result of an operable brain tumour after doctors failed to properly monitor her scan results, an investigation by the health Ombudsman found .
May Ashford, who was 71 when she died, was diagnosed with a brain tumour at the Royal Preston Hospital in 2010 after experiencing headaches and seizures. Despite regular MRI scans showing the tumour was growing and "pushing her brain to one side", she was advised that the tumour "was not growing and was not offered surgery to remove it until May 2015", the Parliamentary and Health Service Ombudsman found.
Mrs Ashford, who lived near Blackpool, was not offered surgery until it was too late because medical staff had failed to correctly monitor the scan results and did not report significant findings, according to the investigation.
The Ombudsman was told by independent medical specialists that Mrs Ashford should have been offered surgery 3 years earlier. They advised that as the tumour grew and affected the surrounding area of the brain, the more likely it was that she could be injured or die following surgery. Mrs Ashford died from a stroke in 2015 following surgery.
An Avoidable Death
Ombudsman, Rob Behrens, said the case emphasised once again the need for urgent improvements to imaging practices in the NHS. "This tragic case highlights why we have been calling for imaging improvements to be treated as an urgent issue of patient safety," he said. "Our casework shows that sadly, Mrs Ashford is not the only person who lost her life because of mistakes related to scans and X-rays. Timely analysis and reporting of scans is fundamental to the diagnosis and management of many health conditions. The sooner we see changes made, the fewer people we will see harmed by these entirely avoidable failings."
The investigation was initiated after Mrs Ashford’s husband, Alan, became concerned about the care she had received and requested a copy of her clinical records. He submitted a complaint to the trust in 2016, and the case was later taken up by the PHSO.
Mr Ashford commented: "Thanks to the Ombudsman’s meticulous report, new rules regarding the monitoring of patients have been implemented by the hospital to ensure that this cannot happen again to anyone else. My wife suffered horribly from the effects of the tumour for more than 4 years, and it was obvious to the family and myself when reading the scan reports that the monitoring of her tumour was highly suspect.
"The tumour should have been removed before it came into contact with the carotid artery. The fact that it was not, is a complete mystery to us. We have no idea why the consultant concerned acted in the way that they did, and as we have never been offered an explanation, we have no closure."
The PHSO recommended that Lancashire Teaching Hospitals NHS Foundation Trust pay Mr Ashford £15,000 "in recognition of the significant distress he experienced because of the Trust’s failings in his wife’s care and handling of his complaint".
The Royal College of Radiologists told Medscape News UK it was not in a position to comment on the Ombudsman’s report.
"Unreserved Apology" From Hospital Trust
In a statement sent to Medscape News UK, a Lancashire Teaching Hospitals spokesperson said: "As a Trust we acknowledge the findings of the Parliamentary and Health Service Ombudsman report relating to the care of Mrs Ashford and have offered our unreserved apologies to Mr Ashford.
"A detailed action plan was provided to Mr Ashford in November 2022, describing the measures that have taken place following the PHSO investigation to ensure that other patients and their families do not have a similar experience."
"Slow Progress" to Improve NHS Imaging
In 2021 the Ombudsman published a report on NHS imaging that highlighted repeated failings in the way X-rays and scans were reported on and followed up across NHS services.
The PHSO led a call, alongside NHS England and the Royal College of Radiologists, to urge the Government to prioritise improvements to the way scans and X-rays are carried out and reported on. Since then, a collaborative effort across the NHS to implement the recommendations, but progress had been slow, according to the PHSO.
"As this case highlights, this essential work must be prioritised to make sure patients are protected from harm," the Ombudsman said on Thursday.