Final report on Oxfordshire Breast Screening Service incident
28/06/2016
This article is more than eight years old.
Oxford University Hospitals NHS Foundation Trust (OUH) has today (28 June 2016) published a final report following the review of an incident declared within the Oxfordshire Breast Screening Service (OBSS) in 2014.
The report provides a detailed account of the incident in which a total of ten women were found to have had a delayed diagnosis of breast cancer after assessment by a single doctor. Since March 2014, following notification of this incident, women attending the assessment clinic now have their imaging reviewed by two radiologists. This is best practice and reduces the risk for human error which was the underlying cause of the incident.
The primary focus of the Trust’s incident investigation was patient safety and recall. A review of the individual doctor’s screening assessment practice was also completed. The doctor concerned has not undertaken assessments since the investigation began and has not returned to this element of clinical practice within the Trust.
Following the recall process, the Oxfordshire Breast Screening Service underwent a routine Quality Assurance review by the National Breast Screening Service. There were no concerns about outcomes for any other women who went through the breast screening service. It is monitored by external assessors who rate it as a unit which performs well and women can be confident about the service they receive.
The Trust’s Medical Director, Dr Tony Berendt, said: "While it has taken longer than we would have hoped to publish the Trust’s final position in respect of the care we delivered, it has always been our priority to thoroughly investigate and to learn from this incident. Specific learning and actions have already been incorporated into standard practice.
"I would like to reassure the women of Oxfordshire that there are no concerns about how the screening service now functions. Women can be confident about the quality of the service they receive. It is monitored closely and the wider investigation of two years ago was triggered by the Trust’s own quality review processes, and related to patients assessed between 2011 and 2014.
"We are extremely sorry for the distress and anxiety that this incident caused to any women who received a diagnosis of breast cancer and to those women who were recalled as part of the incident investigation. We have apologised individually to the women whose breast cancer diagnosis was delayed as a result of this incident."
Breast screening is carried out by the Oxfordshire Breast Screening Service (OBSS) which is part of the National Breast Screening Service (NBSS), commissioned by NHS England.
Through the NBSS all women aged between 50 and 70 are invited for breast screening every three years. In Oxfordshire this service is offered through the OBSS which is provided by Oxford University Hospitals NHS Foundation Trust.
If there are concerns about an initial screening mammogram (X-ray of the breast) then a woman is invited for further tests through what is known as an 'assessment' at the Churchill Hospital. In Oxfordshire, around one in every 16 women who have initial screening mammograms are invited back for further assessment and more tests.
This can involve further mammograms, biopsies or breast ultrasound. If nothing unusual is found then the woman is invited back for a routine mammogram in three years' time.
Mammograms are carried out by the breast screening service and read by radiologists. The service and performance is regularly monitored externally and internally. It was through this regular monitoring that the issue with some assessments was identified.
For further information please contact the OUH Media and Communications Unit, Melanie Proudfoot: 01865 572984