Hospital alerts dozens after failure to relay imaging results turns deadly

Australian health officials have issued an apology after determining that dozens of patients had pertinent imaging findings fly under the radar of their provider for months. 

The unexpected death of a patient at Caboolture Hospital in Australia prompted an investigation into the imaging department’s communication and image sharing procedures. The patient, who had recently undergone imaging at Caboolture Hospital’s Specialist Outpatient Department, presented to the hospital again in September due to feeling unwell. It was determined during that visit that the patient had advanced stage cancer. 

Reports indicate that evidence of the cancer was visible on the individual’s initial scan, but their images had not been reviewed by the time they returned to the hospital five weeks later. The patient passed away not long after the discovery of their cancer. 

This prompted health officials to launch an investigation into the hospital’s image review processes dating back to April of 2023. That review’s initial assessment indicated more than 21,000 scans needed to be further evaluated, 14,000 of which were considered “high priority.” 

Metro North Health—the largest public health service in Australia—released a statement this week stating that the review of the scans is now complete. Thirty-eight patients included in the review were recalled for follow-up imaging and care. The specific details on their diagnoses have not been disclosed, but Metro North Health Chief Medical Officer Elizabeth Rushbrook, MD, stated that no further deaths have been reported due to the mishap. 

Rushbrook said the incidents occurred following a change in image sharing procedures throughout the organization’s Specialist Outpatient Department. Previously, images were available to providers in both digital and hard copy formats, but that changed in April of 2023 and resulted in the hard copies and discs being inconsistently distributed. This led to many patients’ exams falling through the cracks, delaying their review and any necessary follow-up care. 

The CMO added that every patient’s images have now been accounted for. Metro North Health issued an apology and reassured the public that the hospital has “strengthened its processes to ensure a rigorous approach to medical imaging review is upheld by all clinicians” moving forward.