NHS Breast Screening Programme Quality Assurance Reference Centre Annual Report 2004 London QARC 1 Annual Report 2004 This report by zlr12027


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									          NHS Breast Screening Programme

     Quality Assurance
     Reference Centre

  Annual Report 2004

London QARC             1             Annual Report 2004
This report is produced by the London Breast Screening QA Reference Centre.

Email addresses are: firstname.surname@bartsandthelondon.nhs.uk

Copies of this report can be obtained from:
London QARC
4th Floor
50 Eastbourne Terrace
W2 6LG

Tel: 020 7725 5577
Fax: 020 7725 3484

Copies of the London Statistical report, which compliments this report, are
available from QARC too, and can be obtained from

London QARC                          2                            Annual Report 2004
Annual                 Contents
Section 1     Forward by the QA Director                         Page 4

Section 2     The Breast Screening Programme – National Update   Page 5

Section 3     London Quality Assurance Reference Centre (QARC)   Page 7

Section 4     QARC Personnel                                     Page 10

Section 5     Study Days and Workshops                           Page 12

Section 6     Report from QA A&C Co-ordinators                   Page 14

Section 7     Report from QA Breast Care Nurse                   Page 17

Section 8     Report from QA Pathologist                         Page 19

Section 9     Report from QA Physicist                           Page 21

Section 10 Report from QA Radiographers                          Page 25

Section 11 Report from QA Radiologists                           Page 27

Section 12 Report from QA Surgeon                                Page 28

Section 13 Breast Screening Performance                          Page 29

Section 14 Key issues for Breast Screening Services              Page 31

Section 15 Incidents and Early Warnings                          Page 33

London QARC                                3                     Annual Report 2004
 Section 1 Foreword by the
           QA Director
I am very pleased to present this years QA annual report, which reflects a successful year
both for the breast screening programme and for QA. It is also a year that has seen several
developments take place.

During 2004, several new faces joined the QA professional team and QARC and I would like
to welcome them to the team. In June the cervical and breast QARC teams which had been
based at 40 Eastbourne Terrace and at St Bartholomew's Hospital and the Cancer Peer
Review team based at North East London SHA, moved into joint premises at 50 Eastbourne
Terrace, Paddington, London.

The new premises are pleasant and central and having the whole team on one site has
proved beneficial.

From the perspective of the London programme, 2004 saw more than 215,000 women
invited for screening within the capital. Nearly 150,000 attended, resulting in the diagnosis
of more than 1,100 breast cancers. Out of these, 426 were lesions too small to be felt.

Continuing trends set in previous years, clinical standards continued, on the whole, to be
met and sometimes surpassed. Performance relating to coverage, uptake and waiting times
however remains a challenge for many parts of the capital.

Work also continued on the evaluation of the package of proposals which was launched by
the London Health Cabinet in 2003.

The expansion of the screening programme to routinely invite all women aged between
50 – 70 continued to be implemented in London.

The annual study day held in June was, as ever, a key and successful event in the calendar.
We were delighted to welcome a range of experts to present on the day, which attracted
delegates from breast screening services across London and beyond.

A workforce survey showed that London was lagging behind the rest of the country in
developing the new four tier structure for radiographers. This development should be
encouraged as it provides a more flexible workforce for the screening service.

Data collection remains an ongoing issue which received considerable discussion and
proposed actions. It is to be hoped that this will result in improvements in next and
subsequent years.

Finally I would like to take this opportunity to thank the QARC staff, the QA professional
team and those working across the screening programmes in London for their hard work and
input throughout the year.

Using the London Early Warning Protocol for breast screening, several incidents and early
warnings were reported to QA during 2004. Full details of all incidents and early warnings
reported to QA during the year can be found later in this report.

Dr Kathie Binysh
QA Director
London QARC                                 4                                 Annual Report 2004
Section 2             The Breast Screening Programme
                      NATIONAL UPDATE
The NHSBSP Annual Review 2004 entitled "Changing Lives" was published in December
this year reporting great progress within the NHSBSP since the Government‟s Cancer Plan
was published four years ago. Patients were seen to be benefiting from improvements in
detecting and treating breast cancer, with death rates falling faster in this country than
anywhere else in the world (some 30% in those under 70 in the past decade). However, the
report reminds us that breast cancer remains the biggest killer for women in this country,
which is why it remains one of the central priorities for the NHS.

The national annual review reflected the change in demographic of the screening population
caused by the early introduction in some areas of the age extension. The numbers of
women invited and screened during 2004 year rose, with over 120,000 extra invitations and
more than 80,000 additional attendances. This increase was largely due to the expansion of
the programme to include women 65 to 70. However, as they accepted their invitations
rather less often, overall acceptance dropped slightly from 75% to 74.7% when compared
with the previous year.

The rates for assessment and benign biopsies dropped. While this might be expected in an
older population, it was particularly pleasing to see the actual number of benign biopsies
drop given the larger number of women screened and cancers found. Given the slightly
older population, an increased cancer detection rate was both expected and seen. There
was also however an increase in the standard detection ratio for invited women aged 50 to
64 (from 1.22 to 1.32), and a 17% rise in the number of small cancers detected, pointing to
an increase in quality too.

Julietta Patnick, Programme Director, NHSCSP reflected that "these statistics present a
picture of a constantly improving programme and one that is already seeing the impact of the
expansion to women aged 65 - 70 as well as greater recognition of the importance of non-
operative diagnostic techniques".

Another national success during 2004 was the effect of implementing two-view
mammography (where two views of each breast are taken at every screen instead of just at
the first time a woman is screened). A significant increase in the number of breast cancers
detected over the most recent reported year suggests that two-view mammography played a
major role in achieving this.

Recruitment and retention of staff and the development of assistant and advanced
practitioner roles was an important issue for screening services across the country during
2004 and it is believed that the "skill mix" programme has encouraged many more people to
consider pursuing a career in screening. (Unfortunately during the year information gathered
by London QA however found that London was significantly behind our counterparts
elsewhere in introducing the new, four-tier structure).

London QARC                                5                                Annual Report 2004
Other issues that were pertinent for the national programme included the continuing work to
ensure that women are able to make an „informed choice‟ about attending for screening,
increasing accessibility to services and encouraging women to attend for their test.
Increasing difficulties in finding locations for mobile screening units also had a detrimental
effect in many areas. "Changing Lives" (the national annual review) features the innovative
project undertaken by SWLBSS to develop a static screening unit within one of their local
department stores.

The national annual review also focused on the future and reported developments in breast
cancer surgery research such as the use of sentinel node biopsy, which it is believed will
have major benefits for women with a screen diagnosed cancer.

It is estimated that the programme is on course to save over 1,000 lives per year by the year
2010 and Julietta concluded "I have no doubt that our achievements to date give us a great
platform on which to build further success".

London QARC                                 6                                 Annual Report 2004
Section 3              London Quality Assurance
                       Reference Centre
The London QARC is responsible for ensuring the maintenance of national standards and
monitoring the performance of breast screening services within London who participate in

This is achieved through the collection and analysis of mandatory data required by the
Department of Health (DoH) and other national and local agencies overseeing the local
programmes. QARC also acts as a focus for information between these services in the
London region and the National Office.

The importance of good communication cannot be over estimated and the QARC aims to co-
ordinate and support all branches of the service.

The London Cancer Screening Programme consists of:

      5 Strategic Health Authorities (SHA)
      16 Call/Recall Centres
      34 Primary Care Trusts (PCTs)
      7 Breast Screening Services
      Many GP Practices Overseen by the PCTs
      Health Promotion Services.

Office Relocation
In June 2004 the QARC teams based at 40 Eastbourne Terrace and at St Bartholomew's
Hospital, and the Cancer Peer Review team based at North East London Strategic Health
Authority, moved into joint premises at 50 Eastbourne Terrace, Paddington. Having the
whole team on one site has proved beneficial in terms of team development, morale and
particularly efficiency, as staff now do not have to travel between offices.

The new surroundings are pleasant and central, with a large meeting room that quickly
became heavily used for many of the London-wide forum meetings and training events that
QARC are involved with.

London QARC                                   7                            Annual Report 2004
Health Promotion
The pan-London Health Promotion group has had an active year. They developed and
produced a new poster called "Take care of yourself – Take your breast screen" which
encourages women to accept their routine screening invitation. This poster reached a wide
distribution across London with screening service as well as PCTs and health promotion
departments requesting it.

During the breast awareness month numerous projects were carried out by members of the
health promotion group.

Also, contact has been established with a registered charity “Breast Cancer Care” and they
have now joined the group. It is envisaged that good collaborative work with emergence
from this alliance.

Unfortunately no user has been found so far who would like to join the group despite several
approaches. We will be continuing to pursue this next year.

In 2004 a range of NHSBSP publications have been reviewed and released with relevance
to health promotion, the following publications were published:

      NHSBSP (February 2004). Ceasing women from the NHS Breast Screening
       Programme, NHSBSP, Good Practice Guide No 7

      Age Concern and NHS Cancer Screening Programmes. (March 2004). Over 70? You
       are still entitled to breast screening. Department of Health

      CancerBACUP. (2004). Understanding Breast Screening. CancerBACUP

In addition, the NHSBSP has also released a new poster called:
"Open your eyes to Breast Screening"

In 2004, work has begun to review the breast screening service provision across a sector,
looking at health promotion, coverage and uptake aspects of the programme. The first
sector has been reviewed and a final report was issued. The remaining four London sectors
will be reviewed in due course.

The local health promotion group were supported throughout the year by the QA Health
Promotion Strategist.

Overall, 2004 was a busy year for the NHSBSP, and health promotion activities across
London have been steadily improved over the year.

London QARC                                8                                Annual Report 2004
Incidents and Audits
During 2004 QA were involved in two Serious Untoward Incidents (SUI) relating to breast
screening, one regarding women not being invited for screening when due, and the other
relating to a woman not being recalled to assessment when she should have been. An
incident covering breast and cervical screening programmes, relating to a string of malicious
hoax calls to women who had been screened, was also investigated, and the incident
handed to the police. Full details of all incidents and early warnings reported to QA during
the year can be found later in this report.

There were also three full multi-disciplinary audit visits, to South East London Breast
Screening Service (Sidcup branch), South West London Breast Screening Service and to
Barking, Havering and Brentwood Breast Screening Service.

IT Developments
Work to rollout the redeveloped National Breast Screening System (NBSS) continued in
2004. The new system was installed in many units in 2003, and work continued to train A&C
staff in the more advanced skills associated with NBSS including the new "Crystal" reporting
tool. This process was greatly assisted by Sue Hudson, an IT Consultant who was
employed by QA to help everyone concerned through the early usage of the new system.

The redeveloped NBSS project was delivered nationally on time and within budget, which
represents a considerable achievement for the national project team and for WMS, the IT
company employed to rollout and support the new system. Users of the new NBSS, who
took to the new computer system easily, reported it to be a huge improvement on its
somewhat outdated predecessor. Steve Dixon from London QARC was on the National
Project Board which oversaw and co-ordinated the roll out of the system.

National Profile
QARC were very happy to become the host of the national meetings of QA co-ordinators,
following Steve Dixon's election as chair of the group.

Section 60 of the Health and Social Care Act 2001 (Patient
Information Advisory Group)
PIAG has approved the national cancer screening programmes submission for continuation
of Section 60 support for the use of patient identifiable information. This submission was
approved on the basis that all organisations have signed up to the confidentiality and
security policies. In London 100% compliance was achieved with the national confidentiality
and disclosure policy and 99% compliance achieved for the information security policy.
There was one breast screening service which was unable to sign up to the information
security policy but their local IT department is currently working with its Caldicott Guardian to
resolve the issues.

London QARC                                  9                                  Annual Report 2004
Section 4              London QARC
                       QARC PERSONNEL
Joining the QARC team during early 2004 were Katty Jarrah-Layegh (PA to Head of QA)
and Danny Marden (Administrator). Lee Callanan joined the QARC in July to cover Katty‟s
maternity leave. Two additional data administrators, Adeel Khan and Tim Pyke, were also
appointed in February 2004.

Listed below are all QARC staff involved in provision of the QA service for the breast
screening services within London.

                        NAME                                          JOB TITLE
Steve Dixon                                                Head of QA
Carolyn Garritt                                            QA Manager - Breast
Jayne Foster                                               Business Manager
Christiane Zelenyanszki                                    Health Promotion Strategist
William Benjamin                                           Project Manager – Coverage
Tony Robson                                                Information Manager
Dipak Buxani                                               Data Officer
Tim Pyke                                                   Data Officer
Adeel Khan                                                 Data Officer
Kyley Nevard                                               Office Manager
Lee Callanan - covering maternity leave for Katty          PA
Danny Marden                                               Administrator

QA Professional Team
The QA professional team consists of representatives from key professional groups within
the NHSBSP (e.g. A&C, Breast Care Nursing, Medical Physics, Pathology, Radiography,
Radiology and Surgery) as well as a screening commissioner, PCT call/recall team and
Director of Screening representatives. The purpose of the QA professional team is to
devise, implement and drive forward mechanisms to monitor and strengthen the
performance of the NHSBSP throughout London with a view to maintaining achievable
standards and striving for excellence. The team meet on a quarterly basis. Some of the
group also represent London at national QA groups as well as chairing London meetings of
their own speciality.

During the year there were changes to the personnel that make up the professional team.

Eve Smith                                               QA Breast Care Nurse
Pam Lundy                                               QA Commissioning representative
Mike Fitzgerald                                         Physics Consortium Lead

London QARC                                10                                 Annual Report 2004
Listed below are the current members of the professional team.

                       NAME                                            ROLE
Dr Kathie Binysh                                        QA Director
Dr Mike Michell                                         Lead QA Radiologist
Dr Ros Given-Wilson                                     Deputy QA Radiologist
Dr Ruth Nash                                            QA Pathologist
Mr Dudley Sinnett                                       QA Surgeon
Marion Muwanga                                          QA A&C Co-ordinator
Polly Frankfort                                         QA A&C Co-ordinator
Ishmail Badr                                            QA Physicist
Dianne Passmore                                         Lead QA Radiographer
Kaldip Deogun                                           Deputy QA Radiographer
Maggie Luck                                             QA Screening Commissioner
To be appointed                                         QA Breast Care Nurse
Dr Will Teh                                             Director of Screening
Brenda Collier                                          Call/Recall team representative

All of the professional team took part in appraisals, in line with recommendations from the
Healthcare Commission (formerly CHI).

A brief update from each of the disciplines on the professional team can be found in this

London QARC                                11                                 Annual Report 2004
Section 5              Study Days and
Annual Study Day
The annual study day took place on 11th June 2004 at the Commonwealth Institute in
Kensington. As ever, it was well attended and the various presentations were well received.
Due to proposed redevelopment of the area, this was the last year that this venue could be
used and an alternative venue will need to be identified for 2005.

Guest speakers during the morning sessions included Dr Gill Ross (Royal Marsden) who
talked about high risk screening and Dr Matthew Wallis (Coventry) on interval cancers and
round length.

Dr Wallis and Mr Mike Dixon offered challenging commentary as outsiders on London‟s
clinical performance in the previous year.

The topic for the afternoon session was disclosure of audit. This was chaired by
Dr Mike Michell, with input from Dr Joyce Liston (Leeds) as a Radiologist, Mr Mike Dixon
(Edinburgh) as a surgeon and Sarah Illingworth (Breakthrough) as a patient representative.

The study day also provided an opportunity for formal sessions for each discipline to meet,
as well as demonstration multidisciplinary meeting at which non clinical staff could see how
decisions on each patient‟s clinical pathway are reached.

Coverage Workshop
During 2004 two workshops were organised by London QARC to investigate the area of
coverage for both breast and cervical screening programmes across London. The first
workshop took place on Friday 9th July 2004 at the Commonwealth Institute.

The theme for the workshop was “Sharing Best Practice”. The range of speakers included
Dr Ian O‟Sullivan from the Office of National Statistics who presented a paper on the
effectiveness of using pre-invitation letter in order to encourage women to attend for their
screening appointments. Also, Steve Dixon, Head of QA – Cancer, London provided an
update on the Package of Proposals for London. These are a range of proposals developed
jointly by the Strategic Health Authorities (SHA) for London with the Directors of Public
Health, to improve the uptake and coverage of breast screening across the region. Patrick
McGinley from Central & East London Breast Screening Service gave details about a
scheme to use payments to encourage GPs to improve the delivery of screening from the
viewpoint of primary care. The final speaker was Debbie Harris who gave a presentation on,
improving the service and improving uptake of cervical screening, which received the highest
rating of all four sessions, but they were all well regarded by those attending.

London QARC                                12                                Annual Report 2004
Later in the year a second workshop took place on 14th December 2004 in the meeting
rooms at the new offices in Eastbourne Terrace.

“Another Viewpoint, Sharing Best Practice”, changed the format for the workshop. There
were three introductory sessions, which were then followed by three workshop-style question
and answer sessions and was felt to be a better way of sharing information. This was used
as an alternative to the standard presentation model. It was followed by a question and
answer session at the end. Introductory sessions included Bobbie Jacobson from the
London Health Observatory who discussed the importance of data collection, not only the
need for quantity, but also quality and analysis.

There also followed presentations from David Warburton from NHSIA about the Open Exeter
system and Gill Burgess, Screening Nurse Advisor from Croydon PCT who delivered some
very well received alternatives on improving relationships with primary care.

The topics for the three workshops included looking at the issues that influence coverage
within specific areas and how data collection can help with this process. Then there was
further discussion surrounding the use and distribution of Open Exeter. This was followed
by group debate on the issues involved in developing relationships with black and minority
ethnic communities.

London QARC                                13                               Annual Report 2004
Section 6               Report from QA A&C
In January 2004, we were appointed as QA A&C (Joint) Leads. During this time we have
worked hard to ensure that there has been a good support and communication network for
all A&C staff within the London region.

Audit Visits
Formal audit visits took place at South East London Breast Screening Service (Queen
Mary’s Sidcup), South West London Breast Screening Service (St Georges Hospital) and
Barking, Havering & Brentwood Breast Screening Service (Victoria Centre). The main points
      Staffing Issues (particularly with regard to the age extension)
      Space/Capacity/Refurbishment
      Staff Training
      Service Level Agreements
      Communication
      Round Length
      Right Results Protocol
      Funding
Barking, Havering & Brentwood Breast Screening Service very kindly agreed to pilot the new
A&C audit questionnaire. Although very detailed, the questionnaire proved to be a success
and will continue to be used for all further audits.
Informal visits were also carried out this year. We visited Central & East London Breast
Screening Service, (St Bartholomew's Hospital), Whipps Cross Breast Screening Service,
(Whipps Cross University Hospital), West of London Breast Screening Service (Charing
Cross Hospital) and South East London Breast Screening Service (Kings College Hospital).

New Computer System (NBSS)
Throughout the end of last year and following into this year, all units have had the NBSS
installed and implemented. Implementation of the new computer system proved problematic
with problems with printing, software bugs and downtime and a slower throughput in data
entry whilst staff underwent training and familiarised themselves with the system. However,
overall the process went well and problems were soon resolved.

WMS are the company responsible for the implementation and installation of the NBSS.
Unfortunately the support service provided by WMS, although greatly improved, is not as
comprehensive as with the previous company due to the conditions in the Service Level
Agreement. This should not in anyway be seen as a reflection on the level of service
provided by WMS staff.

London QARC                                 14                             Annual Report 2004
Crystal Reports
The NBSS does not have its own reporting tool. Crystal was therefore the package chosen
by the national office and national administration group to enable all units provide the QARC,
commissioners, etc with the relevant quarterly data as required by the national standards.
However units did not receive Crystal until the latter part of the year. By the end of the year
only four national reports were initially available. Workshops were set up to enable us to
begin writing further reports so that all units can collect the appropriate details. This is
proving to be a lengthy process and will be going.

Crystal reports currently available are:

      Round Length (number of women invited within 36 months from previous screen)
      Round Length by PCT
      Round Length Exceptions
      Time from screening to normal result
      Time from screening to normal result by PCT
      Time from screening to assessment
      Time from screening to assessment by PCT
      Uptake by PCT
      BASO Survival Study
      BASO Main
      Ethnic Groups by PCT
      Film Reader Reports.

Other reports are available but have not yet been verified.

Study Day
A staff survey was carried out to find out the general opinion of the A&C teams throughout
the region particularly in light of the many changes occurring. One of the topics discussed
was having a study day solely for A&C. This idea was met with enthusiasm. It is hoped that
an appropriate study day will be arranged for next year.

Yemisi Oluyede – Agenda for Change (AfC) Project Manager at Barnet & Chase Farm
Hospitals NHS Trust – provided a presentation on Agenda for Change. There was an
opportunity for all members of staff to ask questions. It appears that Trusts across the
region are at different stages with regards to AfC. There is some concern over the job
matching process.

National/Regional Meetings
National meetings are held quarterly. Representation for London is provided, ensuring that
relevant information is disseminated throughout the region. It is also an opportunity for the
representatives to feedback from their regions. Items on the agenda include; business
planning, computer support issues, NBSS, revision of A&C guidelines, problems arising from
local audits etc.

Regional meetings are also held quarterly. Topics for discussion are; computer support
issues, data, QA updates, feedback from national meetings, requests for change etc.

London QARC                                 15                                Annual Report 2004
London Health Cabinet Proposals
Proposals have been suggested in order to improve coverage in the London region.
Suggestions have also been made to modernise the breast screening service. Options
include implementing a call centre, a pan London database, outsourcing mail, bar-coding, list
cleaning etc.

There is great concern from the A&C teams in relation to the above ideas and changes. The
Screening Office Managers will arrange a meeting so that their views and concerns can be
discussed and appropriate comments suggested.

Staffing Changes
In the last year there have been a few staffing changes:

Central & East London Breast Screening Service

Maria Mansfield, the Screening Office Manager, now shares the role with Connie Horth.
Connie also incorporates the QMS role into her remit.

Patrick McGinley is the Service Manager.

West of London Breast Screening Service

Jill Macey retired from breast screening after many years service, her wealth of knowledge
and expertise will be missed.

Denise Scrivener was appointed as the Administration Manager.

South West London Breast Screening Service

Pat Vecchi retired this year. Martin Brealey who had been the Office Manager was
appointed to the role of Business Manager.

There have been many developments over this last year and many future changes to occur
over the next year. We hope that the coming year will be as successful as this year.

Polly Frankfort & Marion Muwanga

London QARC                                16                               Annual Report 2004
Section 7              Report from
                       QA Breast Care Nurse
The year started well with the QA worked shared between Eve Smith QA BCN and
Sam Calder Deputy QA BCN. Eve covered South and West London attending committee
and other regional and national meetings, while Sam covered Central and North London.
Eve resigned as QA BCN in December 2004, in order to pursue a new training opportunity.
Sam provided cover for the remainder of the year. The post will be advertised and
applications invited from all breast care nurses working within breast screening services in

Recruitment remains a problem for some units and currently there are vacancies at five
screening units.

Audit and Other Visits to Units
South East London Breast Screening Service (Queen Mary‟s Sidcup) – 27th January 2004,
South West London Breast Screening Service – 10th February 2004 and Barking, Havering &
Brentwood Breast Screening Service on 28th September 2004.

In addition to the formal audit visits, informal visits were carried out to Barking, Havering &
Brentwood Breast Screening Service, WOLBSS, Whipps Cross BSS, South East London
Breast Screening Service (King’s College, Queen Mary’s, Sidcup), and North London Breast
Screening Service. The remaining units were contacted by phone and it is anticipated that
they will be visited in the coming year.

National Meetings
National meetings were held in July 2004. Eve Smith attended the meeting in July and in
addition was a member of a sub group that met three times to formulate an audit tool for
nurses working in screening. The work of the subgroup is ongoing. In practice, the role of
nurses within the screening programme is so diverse that it may take some time to formulate
an appropriate tool. Nurses in some units already carry out workload audits and write an
end of year report for inclusion in the unit annual report and this practice was commended
and encouraged by the national group.

Regional Meetings
There were ongoing problems with attendance at the regional meetings, mainly due to
nurses having clinical commitments. In an attempt to address this, the group agreed to meet
twice a year as opposed to four times a year, which is what the other professional groups do.
A meeting was held in May and all but one unit was represented. However, the meeting
scheduled for October was abandoned when only two units were represented. This issue
was discussed at the QA committee meeting and there was agreement from the Directors of
Screening that every effort should be made for at least one nurse from each unit to attend
the nurses meeting. Future dates will be agreed at the regional study day and nurses will be

London QARC                                 17                                Annual Report 2004
asked to notify their Directors of Screening. It was also suggested that an evening meeting
might be more convenient and this will also be raised with the nurses.

QA Committee Meetings
The QA nurse or her deputy attended the QA meetings, participated in the work of the
committee, and circulated information from meetings to the nurses in the region.

Regional Study Day
The day was well attended and Sam Calder led the nurses group in a discussion related to
Agenda for Change. Nurses expressed concern about job evaluation and matching and
were unsure what impact this would have. Nurses were advised to urgently review and
update their job descriptions and to include all aspects of their work, particularly any new
working practices not outlined in original job description. At the time of the study day, breast
care nurse posts at the AfC pilot sites had not been job matched.

Eve Smith

London QARC                                 18                                 Annual Report 2004
Section 8              Report from
                       QA Pathologist
This report gives a brief summary of activities that the QA Pathologist and other pathologists
within London have been involved in during the past year.

QA Audit Visits
Three audits visit were carried out during the year, the first of which was to South East
London Breast Screening Service (Queen Mary's Hospital, Sidcup) in January 2004. This
found a good quality service with satisfactory QA statistical data, but severe staffing
shortage (in common with many pathology departments).

The second visit, in February 2004, was to the South West London Breast Screening
Service (St George’s Hospital), and was carried out by Dr Sami Shousha.

Finally, in September 2004, there was an audit visit to Barking, Havering and Brentwood
Breast Screening Service (based in the Victoria Centre), for which pathology is carried out in
the histopathology department of Harold Wood Hospital. This found a high-quality,
committed service with good QA performance statistics, but a fluctuating staffing situation
with the impending arrival of new consultant appointees.

EQA Scheme
Pathologists who report breast screening specimens participate in the national External
Quality Assurance (EQA) Scheme. Many pathologists who are involved in symptomatic
work also participate in this scheme, making a current total of around 80 participants in the
London region. The scheme is managed nationally (from the Nottingham-based national co-
ordinating committee) but is administered locally by the QA pathologist with invaluable
support from the QARC. Thus there were two EQA slide circulations during the year 2004
as usual. Each circulation was followed by a regional feedback meeting, incorporating a
participants‟ business meeting, and chaired by the QA pathologist.

The first of these was held as part of the London region study day (see below) and the
second meeting was held on 3rd November 2004 at the QARC at Eastbourne Terrace – our
first at these new premises. Useful discussions took place, and the pathology feedback was
greatly facilitated by CD-ROMs (comprising histopathological images of the cases, plus
relevant statistical data for each case) which are now regularly produced by
Dr Clive Wells (as chair of the national information group).

EQA performance of the London region pathologists as a group remains good, with a mean
kappa statistic (measuring consistency of reporting) of 0.79 over the last four circulations,
compared to the national average of 0.78. However, attendance at these meetings is
generally rather low (although slightly improved over 2003), and reflects the pressure of work
which continues to affect many pathologists at the current time.

London QARC                                19                                 Annual Report 2004
Study Day and Other Meetings
The regional study day was held on 11th June 2004 in the Commonwealth Institute, and was
attended by 14 pathologists. Annual KC62 data were presented (including pathological
information), and there were presentations focussing on high risk screening and on the
effects of round length and “slippage” on the efficacy of the programme; again, a
demonstration MDT meeting was held for the benefit of some of the A&C staff.

In the pathology specialty subgroup we had a short business meeting, followed by an
educational lecture by Dr Clive Wells (“Cytokeratin 5/6 and its diagnostic usefulness”) before
the usual EQA results feedback session.

The QA pathologist attended the national coordinators‟ meetings which, in 2004, continued
finalisation of the revised “Guidelines on Pathology Reporting” (published January 2005),
and also attended a multidisciplinary update course organised by the Royal College of
Pathologists and held in Guernsey (March 2004). The QA pathologist has given local
lectures as required, including regular lectures on courses for advanced practitioners at the
Jarvis Centre and the St George‟s Regional Training Centre.

Dr Ruth Nash

London QARC                                 20                                Annual Report 2004
Section 9              Report from
                       QA Physicist
This report gives a brief summary of the QA activities of the London Region Mammography
Physics Consortium (LRMPC), which provides medical physics services to the breast
screening services in the London region. The report covers the period January – December

Mammographic X-Ray Equipment Performance
All x-ray equipment has been tested against NHSBSP, IPEM77, IPSM59 and other
standards where applicable. The equipment was generally found to perform well over the
period, and there were no major performance issues. A number of minor problems were
highlighted and, in general, good support was offered from the service engineers in getting
them resolved. The Pritchard criteria for image quality, radiation dose and optical density
were found to have been met in the majority of cases, with a small number of exceptions,
mainly caused by small fluctuations in film optical density. The full results are given in the
KC62 statistics and details of other equipment faults are kept with the QARC. The data are
notified to the QARC on a standard reporting template which allows easier collation of the
KC62 data and prompt notification of equipment performance and safety related issues.

There were no instances of equipment performance reaching the suspension level.

Digital Mammography
The new digital mammography units were installed at the Barts Centre and commissioned
by the Barts physics team. A number of issues specific to full field digital mammography
(FFDM) were identified, and these are likely to have implications across the region as the
number of FFDM units increases.

1. The principal differences in terms of quality assurance testing between conventional
   screen/film (analogue) systems is the digital detector itself and the hardcopy and
   softcopy display devices

2. The digital x-ray system will take slightly longer (perhaps 30%) to test compared to
   analogue units. More of the measured data are obtained in the x-ray room (Pixel Values,
   Signal to Noise Ratios and alignment measurements) and therefore the mammography
   x-ray room is needed for longer periods

3. The softcopy and hardcopy devices are additional items to be tested and will require the
   development of QA survey forms and databases

4. The first year presents the greatest strain on physics services as practical and workable
   protocols, survey forms and reporting systems (e.g. writing a new database to store QA
   data and generate reports) need to be developed

London QARC                                 21                                Annual Report 2004
5. It is likely that a full assessment of the digital image receptor will involve the use of
   objective image quality parameters such as variance images, noise power spectrum and
   modulation transfer function. In order to perform this numerical analysis, physics staff will
   probably have to spend considerable time learning the theory of objective image quality
   analysis as well as some computer programming skills. The service will require
   advanced software to write or implement image quality analysis software

6. Additional equipment is required for the physics service. The TORMAX test object is not
   designed to assess the image quality of digital detectors and hence a more suitable test
   object such as the CDMAM contrast-detail test object is a necessity

7. It will take time for physics staff to gain experience in dealing with new types of
   equipment fault associated with digital detectors and display devices

8. The current generation of digital x-ray detectors are not robust and require frequent
   replacement (perhaps annually). This places great additional strain on the physics

The consortium has participated and contributed to a national research programme centred
at Nottingham into the development of QA in breast ultrasound scanning. The focus of the
project is the use of objective image analysis techniques as a means of reducing the effects
of variability and subjectivity arising from the visual assessment of test images. In practice, it
is required to video capture test images, run computer analysis on them and commits the
results to a database, all in addition to continuing normal assessment procedures. This has
involved considerable extra workload, but this has been provided in the interests of service
quality and development. The early results are very encouraging, suggesting that aspects of
this type of approach to quality assurance will indeed bring progress and benefit. In
addition, the Canterbury group has continued to provide training to physicists within the
consortium who wish to develop skills in ultrasound quality assurance, including carrying out
assessments of their scanners as necessary, and has stimulated a review of ultrasound
quality assurance at national level through the national co-ordinating group for physics.

The consortium been involved in advising the St George‟s Centre on overcoming DICOM
compliance issues to enable ultrasound images to be printed to a laser imager, which would
give superior images to the thermal printouts currently used. The two options that were
recommended were either to have a private network and connection to the KODAK dry laser
printer or to connect to the Philips PACS already running in diagnostic Radiology. print
quality has improved dramatically, but further tests need to be carried. Written instructions
on its use will be distributed to the users and verbal instruction will be given on an individual

Full details of scanner performance for each breast screening service are detailed in the
annual reports produced by the respective centres.

London QARC                                  22                                 Annual Report 2004
Local Quality Assurance and Calibration
The Canterbury group has developed and provided a software-based system for local QA to
its centres in the South East for some time that has now been extended to its support areas
in London. The system has been very successful in some centres but less so in others, due
to a combination of differences in use and technical limitations. A prototype system has
been developed over the year and is now ready to update and progress the existing
provision. Key changes are the facility to read sensitometric strips automatically, and the
development of an algorithm to enable changes in x-ray spectrum to be accounted for. The
design philosophy is to enable the system to indicate not only the presence of a problem but
the cause, all stemming from a design that, unlike commercial options, is specialized to
mammography. The spectral algorithm can also be used to help conduct the re-calibration
of mobile units in situations where travel restrictions between the mobile and the film
processing centre make it impractical (or impossible) to conduct the calibration normally.
Such an exercise, based on the theoretical prediction of film densities, was successfully
carried out for the Bromley trailer (linked to King’s College Hospital) in 2004. Significant time
and resources have been needed to achieve this progress.

LRMPC Objectives
The London region annual study was used to identify objectives for the consortium for 2005.
Provisional priorities included the following:

1. Possible organisation of a regional study day on digital mammography for all disciplines

2. Commission all new digital equipment and provide advice to radiographers using it

3. Ensure other members of QA team are kept informed of developments in physics or
   equipment that might be of interest or affect them

4. Identify training needs of radiographers, particularly in relation to new equipment

5. Patient dose surveys to ensure that exposures are optimised and there is some
   standardisation across the regional in terms of patient dose

6. Advice in implementation of diagnostic reference levels to comply with IR(ME)R 2000
   and the new IPEM 88 document

7. Ensure that all centres are kept up to date with changes in national performance

8. Keep handbook under review and advise on changes in local QA protocols

9. Use intercomparisons to ensure that radiographers test equipment performs to within

These ideas are to be further developed during the QA action planning workshop in March

London QARC                                  23                                 Annual Report 2004
Training in the Windense software has been provided to a number of centres.

The LRMPC has been involved in teaching on the principles and practice course at
St George‟s Training Centre.

Patient Dose Surveys
Patient dose surveys have been carried out on all units in the region over the period
2003 - 2004. The results are currently being collated and the results and recommendations
will be passed to the superintendent radiographers in the form of a formal written report.
The information will be used to optimise exposure parameters for the x-ray equipment. The
data will also allow comparison of dose levels with the proposed national diagnostic
reference level (DRL), and potentially enable a lower local DRL to be set for centres in the
London region.

General Consortium Issues
The consortium acted in a timely fashion to ensure full cover for the absence of the physicist
from West of London from December 2004 due to maternity leave. Following group
discussion, all of the quality assurance visits and general support are being taken up by the
Canterbury group during this period to ensure support and continuity of service. The
arrangement is viewed as a valuable opportunity to experience and compare how support is
provided. It is worth noting that many UK mammography physics services are currently
struggling to provide a full range of services, hence the capacity for the consortium to
provide cover for an entire programme at relatively short notice is a significant indication of a
strength of this approach to support.

Quality Management
The Canterbury group recently attained accreditation under ISO 9001:2000 for the provision
of Medical Physics Services (January 28th 2005). This includes a wide range of activities
directly linked to mammography physics support, including the production and validation of
software analysis tools, assessment protocols, work instructions, and instrument
calibrations. This step should work to secure and improve standards of service support,
both currently and for the future. Once again, considerable extra work has been required to
achieve this position.

Ishmail Badr

London QARC                                  24                                 Annual Report 2004
Section 10 Report from
           QA Radiographers
This report gives a brief outline of activities and meetings that the Lead and Deputy QA
Radiographers have been involved in during the past year.

Full QA Audit Visits
South East London Breast Screening Service (Queen Mary’s Hospital, Sidcup) audit in
January 2004. Lead QA Radiographer only, as this is the deputy QA radiographers own

South West London Breast Screening Service visited in February 2004. Pre visit in the
preceding week. Both Lead QA Radiographer and Deputy attended.

Barking, Havering & Brentwood Breast Screening Service visited in September 2004. Lead
QA Radiographer only. Deputy away on annual leave.

Informal QA Visits
West of London Breast Screening Service visited in July 2004 and November 2004 by both
Lead and Deputy QA Radiographers. Regular six monthly meetings are scheduled to
support the West of London Breast Screening Service superintendent radiographer. The
next visit is planned for March 2005.

Barking, Havering & Brentwood Breast Screening Service visited by Deputy QA
Radiographer only August. This was to see the new two roomed mobile ordered in
preparation for screening the Redbridge population.

Whipps Cross core group meeting attended by Lead QA Radiographer in April 2005.

Informal visit to South East London Breast Screening Service in February 2004 by both Lead
and Deputy QA Radiographers.

A second informal visit took place by the Deputy QA Radiographer in December 2004
Lead QA Radiographer also attended three meetings during the year at the request of the
newly appointed Head of Training at Kings College Hospital to assist with advice on changes
to the training courses.

Meetings Attended
Regional superintendent radiographers meet quarterly. Meetings are usually chaired by the
Lead Radiographer and minuted by the Deputy. QA committee meetings quarterly attended
by both QA Radiographers. National meetings are held twice per year. The deputy QA
radiographer attended the meeting in May, and the Lead QA radiographer the meeting in

London QARC                                25                                Annual Report 2004
Both QA radiographers attended the Symposium Mammographicum in Edinburgh in July
2004. The Lead QA radiographer attended a national QA workshop in Birmingham in
November 2004.

London Regional Study Day 11th June 2004
Both QA radiographers assisted with the organisation of the radiographer speciality session.
A speaker from the Society of Radiographers was invited to answer questions from the
radiographers on AfC.

Other Activities
The work on obtaining funding for a clinical education facilitator for London breast screening
was ongoing and time consuming. Several meetings were attended in order to keep the
breast screening funding bid constantly in mind!

The bid for funding was successful, and the job description, person spec. and advert had to
be written. The post is currently being advertised (January 2005).

The lead QA radiographer has been part of a small working party rewriting NHSBSP
Publication 21.

The two QA radiographers have outline plans for a study day for October 2005 to be held in
conjunction with the breast care nurses.

Quality Standards
The standard of mammography across the region remains good and is monitored by
superintendent radiographers and by the QA/deputy radiographers on formal and informal
visits to units.

The technical repeat rates are monitored regularly and are within NHSBSP guidelines for the

There are evaluations of full field digital equipment being undertaken at three centres in
London. These are SE London (Kings) are evaluating a Fischer mammography machine,
Central & East London Breast Screening Service are evaluating a Lorad Selenia in the static
unit, and North London Breast Screening Service are to evaluate a Lorad Selenia on a
mobile screening van.

Career Development & Staffing
There are 13 qualified radiographer film readers and two qualified AP's in the region. Three
more film readers are in training, and there are five trainee AP's. Two radiographers have
qualified in breast ultrasound and a further two are training. Three radiographers are trained
in breast interventional techniques.

Dianne Passmore & Kaldip Deogun

London QARC                                 26                                Annual Report 2004
Section 11 Report from
           QA Radiologists
The follow report outlines various meetings and audit visits that the lead and deputy QA
radiologists have been involved in over the past year.

Regional Meetings
Attendance at London region QA committee meetings on 19th March, 18th June, 17th
September and 17th December 2004.

Audit Visits
South East London Breast Screening Service (Queen Mary’s Sidcup) on 27th January 2004,
South West London Breast Screening Service on 10th February 2004
and Barking, Havering & Brentwood Breast Screening Service on 28th September 2004.

National Meetings
Attendance at national radiology QA meetings January 2004 and June 2004.

Key items discussed at the national meeting included a review of breast screening radiology
QA audit figures for 02/03 which have shown a sustained high SDR for the UK and in
particular an improvement in the SDR for incident screens which is thought to be due to the
implementation of two view screens.

Double reporting by radiographers – as an extension to the skill mix programme of advanced
practitioner radiographer film reporting, there was discussion regarding double reading of
screening mammograms by radiographers. Papers were presented by Roger Blanks for
setting up a trial to measure the sensitivity and specificity of this method.
Further developments to the NBSS – potential updates to the assessment data and
individual reader QA reports were presented and discussed by Matthew Wallis. There was
feedback from a National interval cancer meeting by Will Teh.

Annual Study Day
Attendance and presentation at London region QA study day in June 2004.
The programme was co-ordinated by Dr Ros Given-Wilson and the St Georges Hospital
Training Centre. The study day was well attended and included a review of the London
region breast screening QA results with critical commentary from visiting radiologist and

Other Training/Meetings
Both Dr Michell and Dr Given-Wilson are current members of the DOH advisory committee
on breast cancer screening and attended meetings during 2004. Dr Given-Wilson has
continued the development of QA peer review and team training sessions.

Dr Mike Michell and Dr Ros Given – Wilson

London QARC                                27                                Annual Report 2004
Section 12 Report from
           QA Surgeon
I was appointed a QA surgeon in July 2004 following the retirement of Mr Mike Burke form
the post earlier in the year. I would like to take this opportunity to thank Mike for all the hard
work and enthusiasm he gave to the post.

The national figures for breast screening in the BASO audit were presented at the annual
meeting which this year was held in Nottingham, due to severe fire damage to the
Motorcycle Museum in Birmingham. Overall the London region fared favourably with other
regions but our long standing problems with data collection again merited mention. This will
be my main aim in my three years in office to make this system as effective as we possibly

Annual Study Day
The results were discussed thoroughly at the annual London region breast screening study
day at the Commonwealth Institute on 11th June 2004 and a number of possible solutions
were put forward. We will try to implement these as early as possible. This will need the co-
operation of all surgeons treating screen detected cancers and all pathologists which I do
hope will be forthcoming.

Other Activities
By the end of 2004 the age extension should be fully implemented across London and we
await with interest to see how much extra work will be generated and what knock on effects
this will have.

I look forward to being able to visit all breast screening units in the region during my three
years in office and to try to work with all my colleagues to help the London region become
one of the most efficient in the country.

Dudley Sinnett

London QARC                                   28                                 Annual Report 2004
Section 13 Breast Screening
KC62 and KC63
During 2004, QA collated and reported information relating to the year 2003/04 for London
from the DoH returns for breast screening, and compared this to national minimum
standards and targets for the NHSBSP.

The reported year saw more than 215,000 women invited for screening within the capital.
Nearly 150,000 attended, resulting in over 1,100 breast cancer diagnosed. This is a lower
attendance figure compared with the previous year but the number of cancers diagnosed
was nearly the same. Out of the breast cancers diagnosed, 426 were small (15 mm or less)
lesions, too small to be felt.

Although clinical standards were generally met during the year, and sometimes exceeded,
London continues to perform poorly in all of the standards relating to waiting times and in
coverage and uptake. Waiting times standards measure timings from screening to normal
result, screening to assessment and the time between decision to operate and actual
surgery. The proportion of women being invited for screening within three years is also
reported upon.

The London Statistical Annual Report was intended for any interested parties, in particular
those working within the screening programme and public health. Commentary was
provided to explain the data and to put it into context of national standards. Copies of the
report are available from QARC too, and can be obtained from

The report reflects the hand work of the clinical teams and breast screening staff and QA
would like to acknowledge their contributions.

BASO Audit Action Plan
Each year QA collate data from each breast screening service for the BASO audit. The
main questionnaire was designed to enable collection of data describing surgical screening
activity. Data was also collected on screening surgical caseload, audit of adjuvant therapy
and the survival audit.

The data was collected in December and then presented at the national BASO study day,
held at the East Midlands Conference Centre in Nottingham on 26th May 2004.

London was criticised for incomplete data, late submission of information and particularly for
a lack of information relating to surgeons with a low screening caseload. QA are working
with the screening services to learn from this and to improve next year.

Each region was asked to draw up an action plan, outlining how they would address any
queries or shortfalls identified in the audit results. For London, eight areas of concern were
identified and the QARC worked alongside the QA Surgeon and his surgical colleagues to
examine these in greater detail.
London QARC                                 29                                 Annual Report 2004
Quarterly Monitoring
QA have developed standardised reports to allow submission of quarterly performance data.
This includes information on round length, waiting times and uptake. Some units had
reported difficulties in obtaining timely and complete information relating to waiting times for
surgery. Information is also routinely collected on interval cancers, complaints and
compliments received.

Commissioners are urged to work with their local programmes, and in particular with their
cancer networks, to encourage good data submission from surgeons to the screening units
and from the units to QA.

Once information is received, QA provide a London wide summary and comparative data for
PCT Commissioners.

Coverage, Uptake and Proposals to Improve Them
The year reported during 2004 showed a drop in uptake. The lower figure of attendees was
predominately due to the catching up exercise by one of the screening services in London.
Delays in screening round length can have a negative impact on coverage. For example, a
drop in coverage may be attributed to delays caused by difficulties encountered in finding a
mobile van site. The reasons for this are varied and complex. Please contact Steve Dixon,
Head of QA for further information. Email S.Dixon@Bartsandthelondon.nhs.uk

London recognises that the coverage statistics show a poorer uptake than elsewhere in the
country in respect of women‟s cancer screening services.

The five SHA‟s in London, together with the Regional Public Health Group and the Quality
Assurance team have developed an action plan covering a package of proposals to increase
coverage. The package included investigating a number of alternative strategies to provision
of breast screening with a view to increasing uptake. For example, building on the initiative in
Croydon where a breast screening service has been integrated into Allders department store
and exploring whether this approach in shops would be feasible elsewhere across the

A range of other initiatives are being explored including utilising the new GMS contract,
considering centralisation of call/recall process, exploring whether regeneration and similar
initiatives can encourage uptake in screening. Further developments will build on
opportunities for more flexible services once the digital mammography evaluations have
been undertaken and when PAC‟s systems are updated with the ICT programme. Similarly
an exercise to increase uptake in breast screening by focusing on women who have never
attended or have not responded to invitations is being explored.

Work on whether there is data available from the private sector which would indicate that in
some parts of London the NHS uptake is poor as there is a considerable private provision is
also being undertaken. These elements are all underway and demonstrate the importance
that is placed on cancer screening across London‟s NHS.

London QARC                                 30                                 Annual Report 2004
Section 14 Key Issues for Breast
           Screening Services
Upgrade/Extension to Programme
Two view mammography is now underway in all breast screening services. The deadline for
age extension (inviting women up to the age of 70) is December 2004. All London services
anticipated being able to meet the deadlines and in fact by November 2004, four units had
already started, with the other three planning to start roll out in December.

Concerns were also expressed by staff in some units regarding sustaining the age extension
during periods of staffing difficulty.

In most places, facilities were upgraded to cope with the increase in workload.

During 2004, the Central & East London Breast Screening Service and South East London
Breast Screening Service (at King’s) moved into new accommodation. North London Breast
Screening Service is overseeing building work on a new centre and work has begun at
Barking, Havering & Brentwood Breast Screening Service to improve capacity in the existing

All of these developments represent an improved experience for clients as well as greater
capacity for the programme.

Plans are still being developed for improved facilities in West of London Breast Screening
Service and South West London Breast Screening Service and both services expect to be
able to begin the age extension on time.

Workforce Issues and Skill Mix
Work continued in conjunction with the Workforce Development Confederation to develop a
post to help facilitate training under the new skill mix design. The four tier skill mix aims to
provide structured career paths and roles based on skills and experience rather than
profession. It aims to improve recruitment and retention, promote lifelong learning and help
practitioners develop their full potential. The structure is made up of: consultant practitioner,
advanced practitioner, state registered practitioner and assistant practitioner. The two main
roles being developed in London are assistant practitioner (who can take mammograms
under supervision) and advanced practitioner (whose role involves clinical breast
examination and breast ultrasound)

The NHSBSP produced the second report on the new ways of working in June 2004. This
indicates a significant increase in the assistant practitioner workforce and decrease of one
third in the number of vacancies for radiologists. QA undertook a London wide survey of all
staff employed in the breast screening programmes, which indicated disappointing progress
across London in implementing skill mix. Nationally, there are 82 assistant practitioners in
post, with only two of these being in London. Similarly out of 151 advanced practitioners in
post nationally, only 11 are within London.

London QARC                                  31                                  Annual Report 2004
To help address these issues, QA submitted a bid to South West London WDC for funding a
post of Clinical Learning Facilitator to cover all London breast screening programmes. The
bid was successful but the allocated funding was only for one year. QA and radiography
colleagues felt that a three year tenure of the post would be much more suitable. QA were
therefore required to give assurance that succession funding would be available to support
any allocation from the project beyond year one.

QA have approached the five cancer networks for funding beyond year one and are awaiting
to hear whether this will be possible.

London QARC                               32                              Annual Report 2004
Section 15 Incident and Early Warnings
           Reported to QARC During 2004
Using the London Early Warning protocol for breast screening, the following were reported to
QA during the year. Each event‟s status is shown as at the end of December 2004.
Ref No:                            C.2004.1 (I8)
Type of Incident:                  Incident
Dates:                             January 2004 to present
Description:                       Malicious hoax calls to women regarding cervical
                                   and breast screening
Status: Ongoing
Summary: Police are investigating a series of malicious hoax calls that have been made
within several areas. The hoax callers are masquerading as healthcare workers and have
been calling women at home and in one instance at work and informing them that they have
had abnormal medical tests or cervical screening results and are seriously ill. Women have
also reported that they are being asked questions of a sexual nature and in some case; the
callers are making lewd comments.

Some arrests have been made and computer hardware seized. The phone calls are far less
frequent but have not stopped entirely. Letters to women being invited for screening, now
contain warnings about hoax calls.

Ref No:                             B.2003.8 (I2)
Type of Incident:                   Incident
Date:                               1st October 2003
Description:                        Right Results
Status: Closed
Summary: A woman contacted service as she had been sent a normal result but hadn‟t
actually attended for screening. Investigations by staff and later by QA found several
breaches of detail within the right results protocol that were not picked up. A report from the
SUI panel was compiled and sent to the BSS, who responded with details of changes to
practice and lessons learnt. The service hope to close this incident, along with the one
below, during September 2004

Ref No:                            B.2003.9 (S2)
Type of Incident:                  SUI
Date:                              8th December 2003
Description:                       Right Results
Status: Closed
Summary: A woman attended for screening in December. On reading her films the
radiologist realised that the woman had been reported on three years ago as needing further
views (FV). Documentation had been filled in by the reporting radiologist to that effect
however the woman was not recalled and her results entered onto the computer system as
normal. A significant contributing factor to the error was that the woman was disabled and
had been separated from the rest of the batch of women and invited to a “disabled” clinic.
The Right Results policies in place for regular clinics was not followed for disabled clinics.
The woman was recalled urgently and cancer confirmed.
An SUI panel was convened and two prospective audits undertaken. No further incidents
were identified from a three year audit of all patients from the same clinic. A second audit –
a general look back of all work undertaken by the service for a two year period – was also

London QARC                                 33                                 Annual Report 2004
undertaken and again no further incidents identified. All batches/clinics are now processed
according to the Right Results protocols.
The final report was presented to the Trust board in October 2004 meeting.

Ref No:                           B.2004.1 (I1)
Type of Incident:                 Incident
Date:                             12/03/04
Description:                      Theft of computer containing breast screening
                                  patient data from histology department
Status: Closed
Summary: There were several computer thefts from the histology department. The PC‟s had
data on them (which was password protected) that contained names of patients, lab
numbers and diagnosis, for research purposes. The department were able to establish that
the password protection was robust and the only way to use the PC would be to re-format
the hard disk and this would wipe out all of the data. They were therefore very confident that
there was no risk of a breach of patient confidentiality.

A PC was also reported stolen at the local BSS but it contained no patient data. This was
reported to the local police but not recorded as an incident

Ref No:                           B.2004.2 (E7)
Type of Incident:                 EWP
Date:                             19/02/04
Description:                      Workmen cut through power cable to screening unit
                                  during assessment clinic
Status: Closed
Summary: Power was restored overnight.

Ref No:                           B.2004.3 (N7)
Type of Incident:                 Near miss
Date:                             21/04/04
Description:                      In the path lab, a specimen and its form and were
                                  separated and the lab staff felt they could not
                                  guarantee that the specimen and the form were from
                                  the same patient. The biopsy could not therefore be
Status: Closed
Summary: The specimen and form were correctly labelled, but during the clerical data
entry/loading onto cassettes, the form and specimen were separated and the path lab staff
felt they could not guarantee that the specimen and the form were from the same patient,
and therefore the biopsy was not formally reported. The patient had a cancer, and was
referred to a breast surgeon. The biopsy was then repeated. The incident was identified
before the sample was reported, and there was no question of an erroneous report having
been issued, as action was taken promptly.

London QARC                                34                                Annual Report 2004
Ref No:                             B.2004.4 (P7)
Type of Incident:                   Procedural Error
Date:                               June 2004
Description:                        Appointments were not made for a particular batch
Status: Closed
Summary: A computer generated AJ-BCO report was received from one of the PCTs
quoting approximately 400 women outstanding for booking. After checking the computer
system it was identified that this batch had not been received or indeed recorded as waiting
to be sent to the screening office. At the time of the incident a member of clerical staff had
been trained to carry out the PNL procedure and this case has fallen between those that had
been done during this period. Twenty PNL‟s were raised during the period effected and all
PNL‟s have been audited for accuracy of data.

An audit was completed which checked the accuracy of the PNL, recording of PNL data GP
files and missing data that may be present. The audit clarified no further errors had been
made during the period of the clerical officer covering this procedure.

Changes to procedures were also introduced and have now been in place for a period of five
months to ensure that strict audit is completed throughout the PNL process. The practice in
question is currently being invited for screening in June. It is envisaged a screening gap of
approximately two to three months will be experienced.

Ref No:                           B.2004.5 (N4)
Type of Incident:                 Near miss x 2
Date:                             30th April and 25th May 2004
Description:                      Two incidents where incorrect films were found in
                                  women’s film packets that had been recalled for
                                  assessment. In both cases, the women were
                                  correctly recalled for assessment.

Status: Closed
Summary: Incident 1: Patient recalled for assessment did not have her films in the clinic.
The films had formed part of an „arbitration‟ set. The examination was repeated in order to
complete the assessment. The original screening films are still missing. Outcome: correct
recall for assessment – cancer diagnosed.

Incident 2: Incorrect films in film packet of woman recalled for assessment. These were
found to have been switched with a woman who had been given a „routine recall‟ result.
Review of mammograms showed the correct outcome was achieved. Action plan drawn up
by director of service on 27th May 2004.

London QARC                                35                                Annual Report 2004
Ref No:                             B.2004.6 (E8)
Type of Incident:                   EWP
Date:                               14/04/04
Description:                        Shortage of radiologists causing backlog of work
Status: Ongoing
Summary: The service will be losing two of its breast radiologists through maternity leave
and a resignation. In order to replace these two posts the Director of Breast Screening
contacted other screening units to ascertain if there were any radiologists available to
undertake either a substantive or locum post. A locum post was advertised but there were
no applicants. A substantive position was later successfully recruited to, and a new
consultant due to join the service from September. It is anticipated that as a result of the
shortages the screening service could see delays in the length of time between screening
and receipt of normal results and between screening and assessment.

Ref No:                           B.2004.7 (S7)
Type of Incident:                 SUI
Date:                             26/07/04
Description:                      Women not invited for screening due to incorrect
                                  coding of one GP
Status: Final report issued
Summary: A potential incident was reported when it was noted that a woman screened in
June 2004, and diagnosed with breast cancer through her routine three-yearly screening,
had not been invited since 2000. Initial investigations revealed that 205 women had been
invited for screening a year late. Of these women, three were diagnosed with breast cancer.
Once the incident had been reported, those women‟s screening records that were still in the
process of being reported were fast tracked.

Through other administrative checking systems, the unit had begun to investigate what at
first appeared to be an incorrect inclusion of 205 women registered with one GP for
screening during the summer of 2002. It was later established that the women had actually
been assigned to an incorrect GP at the time that they were due to be screened. By virtue of
this they had been overlooked for screening. They were consequently sent appointments for
screening in June 2004.

An investigation was carried out which assured all parties that the error had not been
repeated. Independent to the incident, changes had been introduced in working practices
that would have prevented a re-occurrence.

NB This incident was not reported in accordance with national & London wide QA guidance,
which requires immediate notification of a potential incident to be made to the QA Director.
This was reported to the SUI panel.

London QARC                                36                                 Annual Report 2004
Ref No:                           B.2004.8 (I8)
Type of Incident:                 Incident
Date:                             26/08/04
Description:                      Incorrect labelling of mammograms resulted in
                                  wrong woman being recalled for assessment
Status: Ongoing
Summary: An incident was noted when a woman requiring further views was not recalled to
assessment and a woman with the same surname and similar screening number, who had
not attended her screening, was recalled to assessment. Both women were part of the
same screening clinic in July 2004.

Outcomes for both women have now been correctly carried out and an action plan to
address this incident has been put in place. In addition to actions involving training and
clinical governance, the action plan includes: a review and audit of relevant processes and
work instructions; a retrospective audit of assessment clinic DNAs over the past six months
to determine whether all women have been correctly recalled to assessment; and a formal
Trust risk assessment already planned for September 2004 to look into incidents related to

NB This incident was not reported in accordance with national & London wide QA guidance,
which requires immediate notification of a potential incident to be made to the QA Director.

Ref No:                             B.2004.9 (E7)
Type of Incident:                   Early Warning
Date:                               10/11/04
Description:                        Staff shortages – radiographers and radiologists
Status: Ongoing
Summary: The service is set to lose several key members of staff in the near future; five
radiographers have resigned, lured by enhanced pay at other screening units. One
radiologist is set to go on maternity leave shortly and another has resigned.

The total staffing loss is eight radiology sessions per week and almost 150 working hours
from the radiography pool. The service is assessing the expected impact, and feels that it is
inevitable that this will force them to reduce their workload, hence introduce a delay to the
screening round, until the posts are filled.

London QARC                                37                                Annual Report 2004

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