Radiologist faces blame after ‘inadequate’ CT report overlooks deadly bowel cancer case

Healthcare authorities are faulting a radiologist for an “inadequate” CT report that overlooked a woman’s case of bowel cancer.

The controversy dates to early 2018 when a New Zealand woman underwent an abdominal and pelvic CT. The individual had experienced three months of weight loss and two months of abdominal pain.

However, radiologist “Dr. B’s” report on the CT scan only noted two minor issues but no “obvious malignancy.” He recommended an ultrasound follow-up in three months and the woman was advised by another doctor that her CT showed no obvious issues.

Weeks later, “Mrs. A” was readmitted with severe illness. At this point, the radiologist again reviewed the CT scan and picked up on an abnormality he had missed. Dr. B updated the document with an addendum reporting the finding and need for further assessment. But he did not document whether communication of this change to the original referrer had occurred.

Two days later, another doctor noted the addendum, according to the Health & Disability Commissioner, which is tasked with reviewing medical malpractice claims in the country. Providers completed additional medical review that day, and an MRI unearthed a cancerous mass causing a bowel obstruction. Mrs. A died a few weeks later, with the coroner relaying his concerns about the case to the government watchdog.

After an investigation, Deputy Commissioner Carolyn Cooper determined that the radiologist breached the code of care for his “inadequate” CT report. This included the failure to mention several important anatomical structures in his analysis.

“I consider that the CT report was inadequate as it did not mention the gastrointestinal tract, the retroperitoneal structures, or the pelvic organs, and whether or not these appeared normal,” Cooper said in an Aug. 12 news release.

According to a detailed report of the incident, the radiologist had said he could not recall what triggered his re-read of the original CT scan. However, when the clinical director of the radiology department analyzed the audit trail, it showed that two radiologists had reviewed Mrs. A’s images. About two hours later, Dr. B added the addendum. Therefore, Cooper and colleagues wrote, the “most reasonable assumption” was that the radiologists alerted Dr. B. to the finding and told him to add an addendum.

The radiology department’s policy stated that, when making an addendum that differs from the initial report, a radiologist must bring these results to the referrer’s attention by phone. Despite this, current systems at the hospital required the radiologist to select an alert flag outside of the body of the report within the information system. This went to a worklist where the administrative team would send an email to the referrer, alerting them of the abnormal finding.

“From the information provided to me, I consider that Dr. B followed the processes that were in place at Health NZ,” the investigation noted. “However, I am critical of the alert system and the process that was in place for documentation of addendums. Clear documentation of when and how the addendum was conveyed to the relevant parties could have prevented confusion in Mrs. A’s care and the subsequent delay caused by the confusion. However, the alert system and process for documentation is not outlined within Health NZ’s policy. Although Health NZ has stated that it is extremely unlikely that a radiologist would not notify a relevant clinician if a significant miss was identified, I consider that Health NZ’s internal audit finding reflects a systems issue in relation to the use of the alert system and the reporting of addendums.”

Following the incident the Health & Disability Commissioner is recommending providing a written apology for the deficiencies, undertaking an audit of 50 random radiology reports, and providing the office with an updated written policy on how to handle addendums.