Patient X – delayed diagnosis of cancer

We used the Eva technology to investigate a serious patient safety incident involving a ten month delay in the diagnosis of a bladder cancer.  The incident happened in a district general hospital and resulted in serious harm to the patient.  The care and treatment covered an eighteen-month period.

In this case the on-screen timeline brought to life a complex history of events and interactions between health services and the patient. These included outpatient attendances, visits to the GP and presentations to the emergency department of the local hospital.  The chronology allowed the investigator to establish a thorough understanding of events and see these in an on-screen display.

The timeline immediately brought to life the problems in the care of the patient.  They included:

  • CT urogram scan results not being seen by the requesting doctor or the surgeon
  • The radiologist not reporting the patient’s cancer to the MDT
  • The patient remaining on a general urology rather than cancer pathway
  • A trainee surgeon not taking a biopsy when carrying out a cystoscopy because of the absence of scan results

Further analysis  in Eva revealed that the underlying EPR system did not flag unexpected, abnormal test results to requesting doctors.  Instead, requesting doctors had to read all reports or rely on the radiologist emailing them and the cancer MDT to report unexpected findings.

Eva allowed us to see how  underlying system issues contributed  to the incident.

Our report made three recommendations to reduce the chances of the same thing happening again.  They included a ‘red flag’ reporting system for unexpected clinical findings, a failsafe system for allocating a patient to the right pathway and the timely reporting of written reports from radiologists.