Portsmouth Hospitals NHS Trust release statement regarding publication of Board paper on lessons learned from CQC section 31 notice and harm review
John Knighton, Medical Director for Portsmouth Hospital NHS Trust said:
“In December 2017 the CQC published a report on the radiology service at Portsmouth Hospitals NHS Trust which highlighted delays in the reporting of chest x-rays. At the time we committed to providing a further update once we knew more about the reasons why we fell short of the high standards expected of us. Our Board has now received a report on the lessons we have learned as well as the findings from an independent review.
At the end of February we delivered on our commitment to complete a review of the backlog of chest x-rays. This has shown that the vast majority of chest x-rays were interpreted sufficiently well by clinicians to ensure that patients received the appropriate treatment. From a total of over 30,000 chest x-rays reviewed, four patients have so far been found to have suffered significant harm as a result of their x-ray not having been interpreted by a trained specialist.
Clearly any patient who suffers harm that could have been avoided, is one too many. All affected patients or families have been spoken with. The anxiety and distress caused to them will have been profound and enduring and we apologise unreservedly. No patient is ever thought of as a number or statistic, but in order to provide reassurance to our patients and local community it is important to highlight that those who suffered significant harm represents only around one in ten thousand of all those who did not have their x-ray reported.
In the months since the CQC identified the problem we have taken comprehensive action to remedy the shortcomings highlighted. All chest x-rays from the Emergency Department (ED) are now formally reported by a trained specialist, our reporting policy has been changed to bring it in line with practice across the NHS, we are training dedicated reporting radiographers, as well as providing further training for clinical staff.
In order to provide reassurance that this could not happen again, we commissioned an independent, external investigation into the root causes. This has clearly identified that there were problems in the past with the Trust’s governance processes, however the action we have taken in response to the CQC’s concerns, and the processes now in place are considered to be exemplary.
Since the CQC undertook their inspection last July we have spent time reflecting on the impact of their findings, both on individual patients and on the practice of the organisation as a whole. We are grateful for the spotlight that has been shone on this important issue which has allowed us to take stock, gather evidence and take action to deliver the improvements necessary to provide the best possible quality of care to all those we look after.”