Recurrent failings in the way X-rays and scans are reported on and followed-up across NHS services are highlighted in the report by The Parliamentary and Health Service Ombudsman (PHSO). It identified several cases in which signs of cancer in X-rays and scans were not reported, leading to delayed diagnoses and poorer outcomes for patients.

Another common issue was inefficient handovers between departments and services. The report documents recurrent themes of varied or poor escalation procedures and communication between hospital teams. Investigations also found that trusts did not learn from previous errors related to imaging, which meant they repeated mistakes.

Ombudsman Rob Behrens concludes that failings related to imaging are found across the NHS, in both primary and secondary care services, and not solely in imaging departments. He calls on the government to commit to a system-wide programme of improvements for more effective and timely management of X-rays and scans.

The report – Unlocking Solutions in Imaging – calls for NHS England and Improvement (NHSEI) and the Department of Health and Social Care to prioritise digital imaging system improvements as a key patient safety concern and ensure there is national guidance on radiology reporting roles and procedures. Individual NHS providers should ensure that radiology staff have allocated time for reflective learning, hospital radiology leads regularly collate and share learnings and intelligence of imaging issues, and that the RCR ensures its guidance on the reporting of unexpected significant findings is clear and continually updated.

Ombudsman Behrens, said: "Now, as the NHS recovers from the devastating impact of the pandemic, we have a vital opportunity to learn from the failings and embed system-wide changes to improve imaging in the health service.

"The evidence-led recommendations I have set out should be implemented swiftly, with collaboration across government and the health sector to strengthen the NHS’s recovery."

RCR President Dr Jeanette Dickson commented: "The Ombudsman’s call for NHS digital shortcomings to be addressed as an urgent patient safety matter is both bold and pivotal. The Covid-19 response has demonstrated the NHS can make rapid digital improvements, such as rolling out remote and networked scan reporting. Innovations in imaging IT must continue as the health service recovers, and trusts must be centrally supported to allocate the staff time and capital investment needed to upgrade IT and alert systems.

"Hospital imaging teams are under more pressure than ever, battling through Covid backlogs on top of spiralling demand for radiology scans and procedures, and it is crucial that any system and local-level efficiencies that can happen, do. Staff desperately need breathing space to implement systems change, but this will only take us so far.

"Latest RCR staffing data shows the NHS needs at least another 2,000 radiologists to meet demand and ensure safe practice. Recent training uplifts for more radiologists are welcome, but must go further to meet future demand. In the short-term Government, the NHS and trusts must work together to actively support and retain radiology teams, or risk an exodus of exhausted imaging staff."