Woman's avoidable death shows urgent need for improvements to NHS imaging, warns health Ombudsman

A woman died from an operable brain tumour after Doctors failed to properly monitor her scan results, an investigation by the Parliamentary and Health Service Ombudsman (PHSO) has found.

May Ashford, who lived near Blackpool, was diagnosed with a brain tumour in 2010 at the Royal Preston Hospital after experiencing headaches and seizures. Despite regular MRI scans showing the tumour was growing and was pushing her brain to 1 side, she was told that it was not growing and was not offered surgery to remove it until May 2015.

PHSO's investigation found May was not offered surgery until it was too late as medical staff failed to monitor the scan results properly and did not report significant findings.

Independent medical specialists told the Ombudsman that May should have been offered surgery 3 years earlier. As the tumour grew and affected the surrounding area of the brain, the more likely it was that May could be injured or die following surgery. Tragically, May died from a stroke in 2015 after her surgery.

Ombudsman Rob Behrens said this case once again emphasises the need for urgent improvements to imaging practices in the NHS:- "This tragic case highlights why we have been calling for imaging improvements to be treated as an urgent issue of patient safety. Our casework shows that sadly, Mrs Ashford is not the only person who lost her life because of mistakes related to scans and X-rays. Timely analysis and reporting of scans is fundamental to the diagnosis and management of many health conditions. The sooner we see changes made; the fewer people we will see harmed by these entirely avoidable failings."

May's husband Alan brought a complaint to the Ombudsman as he had concerns about his wife's care. He said:- "Thanks to the Ombudsman's meticulous report, new rules regarding the monitoring of patients have been implemented by the Hospital to ensure that this cannot happen again to anyone else. My wife suffered horribly from the effects of the tumour for more than 4 years, and it was obvious to the family and myself when reading the scan reports that the monitoring of her tumour was highly suspect. The tumour should have been removed before it came into contact with the carotid artery. The fact that it was not is a complete mystery to us. We have no idea why the consultant concerned acted in the way that they did, and as we have never been offered an explanation, we have no closure."

The Ombudsman's 2021 report on NHS imaging highlighted repeated failings like those found in May's case. PHSO led a call, alongside NHS England and the Royal College of Radiologists, to urge the Government to prioritise improvements to the way scans and X-rays are carried out and reported on. Since then, a collaborative effort across the NHS to implement the Ombudsman's recommendations has begun, but progress has been slow. As this case highlights, this essential work must be prioritised to make sure patients are protected from harm.

New data shows 71% have never received blind cord safety advice

80% of the UK's population have blinds in their homes, but over 70% have never received blind cord safety advice, that's according to the latest research from the Royal Society for the Prevention of Accidents (RoSPA). This comes after the recent National Child Mortality Database data revealed that looped blind cords and chains have killed 9 UK children between April 2019 and March 2022.

23.6% of UK adults who have looped cord blinds polled by RoSPA and YouGov said their blinds have no safety features fitted, with 20% stating the blinds in their home were already there when they moved in. Worryingly, almost 2 in 3 parents (62%) of children under 5 said they hadn't received any guidance on correct blind cord installation or usage.

Most of those questioned said some or all of the blinds in their home were fitted by themselves, friends or family members (42.95%), while 34% admitted that if they were presented with a scenario where their blinds in their home had no safety mechanism, they would take no action.

Interestingly, although new standards for blinds were introduced in 2014, most of the people polled (41.67%) said they did not know about the changes and consequently did not check if their blinds were compliant, and although changes to blind standards were introduced in 2014, 10% of the people polled had no idea when their blinds were fitted.

Looped blind cords and chains can strangle children and young people. Although changes to standards for blinds in 2014 have led to improved product safety, products installed earlier may not have these safety features and millions of households could be affected.

New blinds with looped cords must have child safety devices installed at the point of manufacture or be sold with the blind.

Ashley Martin, Public Health Advisor at RoSPA, said:- "Our research has come as a stark warning that we must take blind cord safety more seriously. We clearly need to do more to help families with young children, who are disproportionately affected by blind cord strangulation. Our findings suggest that thousands of homes across Britain have non-compliant blinds fitted, but also that families do not know what to look for to ensure their child is safe. We recommend installing non-looped cord blinds, not placing blind mechanisms near beds or cots, and checking whether existing blinds are compliant."

Ashley went on to outline how to reduce the risk of a blind cord accident:- "If you are fitting blinds yourself, and want to ensure a blind cord is compliant, you should follow the instructions supplied with the product and ensure you fit any safety devices included. Safety devices that parents should look out for include tidies, tensioners or cleats. Tidies and tensioners need to be permanently taught and so should be fixed tightly in place so that a blind's cords and chains are held in a rigid position. Cleats should be installed out of grasp from a child, so at least 1.5 metres from the ground. Parents should always ensure cords are tied up (or looped cords removed entirely) if in a room where a child may spend time in. In terms of cleats, it is recommended to curl all looped cords around a securely installed cleat into an infinity symbol. A child's bedroom, however, should never have looped cords fitted whatsoever, and any cots should be positioned away from a window. Parents can ensure their child is safe by never leaving them unaccompanied in a room with looped cords and should consider fitting post-2014 standard blind cords when they have the opportunity."

Further information on blind cord safety can be found at Blind cords - RoSPA.