NHS Fife has apologised to a woman for failing to spot an abnormality in her leg.
The woman, known only as Mrs C, had to undergo two operations to fix the problem in her painful thigh.
Mrs C was suffering from pain in her leg some time after having her hip replaced.
Her GP referred her for an X-ray.
Following that, a report noted there was no abnormality but there had also been no previous images available for comparison, as the patient’s earlier X-rays had been taken in another NHS board area.
Mrs C was later seen by a private doctor, who thought the X-ray did show an abnormality which needed to be investigated.
Further X-rays showed there was a problem with Mrs C’s replacement hip and a possible fracture. Mrs C needed two more operations to fix this.
Later she turned to the Scottish Ombudsman, complaining that NHS Fife has failed to identify the abnormality in her X-ray.
The board took the view that the X-ray did show a subtle abnormality but that without the previous images to compare it to, it was difficult to tell if it was significant.
NHS Fife explained to the Ombudsman that a new system had since been introduced which made it easier to view X-rays taken in other parts of Scotland.
After taking independent advice from a medical adviser, who is a consultant in radiology, the Ombudsman upheld the complaint.
The consultant reviewed the X-ray and took the view that while the abnormality was relatively subtle, it was visible and could have been considered potentially significant for Mrs C.
He said it would have been appropriate to refer Mrs C for further investigations on the basis of that X-ray.
The Ombudsman recommended NHS Fife apologise to Mrs C for failing to identify and report the abnormality and provide a copy of the decision to the doctor to allow him to “reflect” on the case and discuss any learning points at his next appraisal.
Noting the Ombudsman’s report, NHS Fife director of acute services, Heather Knox, said: “We offer our most sincere apologies to Mrs C for our shortcomings in this instance.
“We have carefully considered the results of this report and have taken the necessary steps to ensure that similar incidents do not occur in future.”