Decision Report 201500618

Summary

Mr C underwent a magnetic resonance imaging (MRI) scan (scan used to diagnose health conditions that affect organs, tissue and bone) at the Western General Hospital to investigate back pain he was experiencing. The report of the scan did not mention the presence of an aortic aneurysm (a swelling of the main blood vessel leading away from the heart, down the body). It was only when a further MRI scan was taken two years later that the aneurysm was noted and operated on. Mr C complained that this was unreasonable.

We found that, in their response to the complaint, the board had recognised the error. The error occurred because, while the aneurysm was visible on initial scans (taken to ensure that the full MRI scan would be taken in the correct place), in the main images the aneurysm was largely obscured by images of the spine. The board had discussed this finding with the reporting radiologist (a doctor specialising in medical imaging) and submitted it to the department meeting for wider discussion about the importance of assessing the initial images thoroughly. The board had apologised to Mr C.

We took independent advice from one of our medical advisers. They confirmed that the board should have noted the presence of the aneurysm. The adviser was satisfied that the action taken by the board since the error was brought to their attention was reasonable. However, they suggested that the reporting radiologist discuss the case at their annual appraisal. We agreed with this view. We recommended that this happen and upheld the complaint.

Recommendations

We recommended that the board:

• ensure the radiologist concerned discusses this case at their annual appraisal.