HCS Advisory Board Minutes

​​​​Request 722370798

1. HCS Advisory Board Minutes Thursday 25 July 2024, Section 12, note that the Radiology Department‘s ‘error rate is low and, in all probability, falls within what could be considered a normal range.’ 

I am interested in understanding how instances of missed cancer diagnoses are factored into these calculations. For example, if a patient undergoes a scan that is initially interpreted as clear, but is later diagnosed with cancer within a six-month period, and upon retrospective review, the original scan reveals abnormalities indicative of cancer, how is this scenario accounted for in error assessments?

Could you please provide details on:

Please explain how missed diagnoses, are recorded and how they form part of the error rate 

The processes and criteria used to identify and review such cases.

How these cases influence the overall margin of error statistics.

Any quality assurance measures in place to minimise such occurrences.

2. Referring again to the Minutes, “CB re-emphasised the key point that the concerns had been raised for three years within Radiology but had never been escalated from Radiology to senior management.” 

Please outline the following: 

What mechanisms have been put in place, following this meeting, to ensure complaints are escalated to senior management? 

Following this meeting, what communication has there been to staff to clearly outline when complaints should be escalated? 

Explain your process for escalating staff complaints 

What changes have been made to the policies and process of the Radiology Department to prevent future misdiagnosis, following the mammogram misdiagnosis published in June 2024. 

Response  

1

As noted in the minutes of the 25 July 2024 meeting of the Health and Care Jersey Advisory Board, the external review of mammograms and the findings reported relate to one area of practice of a single Radiologist, rather than the service as a whole.

Error rates are calculated in a standard fashion; missed diagnoses (including any missed cancer diagnoses) are calculated as a percentage of the total patients imaged to produce the outcome / error rate.

In the case of mammograms, when potential errors are identified, the images are added to a meeting where they are anonymised and reviewed. Mammogram readers review the images to assess whether evidence for diagnosis was visible in retrospect. If so, the case is included in the error rate.

In respect of other radiological imaging, Health and Care Jersey conduct Radiology Events and Learning Meetings (REALMS) in compliance with the Royal College of Radiologists guidance:

Standards for radiology events and learning meetings | The Royal College of Radiologists​

The only difference observed in Jersey REALMS from the standard process is that submission in Jersey is not anonymous.

Quality assurance measures include annual inspection of the Radiology Department and their REALMS process by external accreditors; all annual inspections have been passed. The department’s UKAS (United Kingdom Accreditation Service) accreditation can be found online at 7482IQSI​.

2

Several mechanisms exist for staff to raise concerns; these pre-date the Advisory Board meeting referenced. Employees are encouraged to report incidents and raise any concerns that they may have; this may be through established reporting lines for the service area or Care Group (directly and via the incident reporting system), to a Designated Officer, or through the dedicated Freedom to Speak Up Guardian.

A Concerns pathway is in place to facilitate raising concerns to management.

Escalation routes are as follows:

• Concerns raised to line manager (or appropriate clinical lead)

• Line manager investigates nature and reason for concerns

• If information emerges requiring further escalation, this is raised to senior management.

Within Radiology, policy has been reviewed with all staff to ensure awareness of the policy and how to implement this, as well as greater utilisation of the incident recording system to ensure corporate oversight.

Radiology-specific processes for safety:

​• REALMS

• Annual inspection by external assessors

• Regular audit of wires, stereotactic biopsy and screening performance. 

• Concerns policy review. 

• Review of diary bookings to ensure safe quantities of work.

• Replacing old and outdated equipment to allow latest techniques.​​​​