Radiologist reprimanded for failing to disclose difficulties interpreting CT scan, leading to patient’s death

A radiologist should have reported difficulties interpreting one patient’s CT scan, an action that may have helped catch the woman’s liver cancer sooner, according to a recent government investigation.

The case in question dates to 2018, when “Mrs. A” presented to her primary care provider with ankle swelling, weight gain, tiredness, with blood testing that showed abnormal liver enzyme levels. The provider ordered a CT scan and radiologist “Dr. B” noted two lesions. However, he did not denote the possibility of liver malignancy, New Zealand’s Health & Disability Commissioner said in its report on the incident.  

“The radiologist should have reported that the liver lesions identified on the woman’s CT scan were difficult to characterize, and therefore he should have offered a differential diagnosis and recommended further imaging,” Commissioner Morag McDowell said in a statement. “His failure to do so contributed to unacceptable delays in the diagnosis of the woman’s liver cancer,” she added.

Mr. A was later diagnosed with cancer, but the extent and position of the tumor precluded removal. She started chemotherapy with the first cycle going well, but her condition deteriorated, and she died in 2019, according to the report.

“It is not possible to determine with any degree of certainty whether such surgical removal would have been curative," McDowell added.

After assessing the incident, the office recommended reviewing processes within New Zealand’s radiology service to pinpoint ways to prevent interruptions for rads who are undertaking complex analyses. The commissioner also “strongly” encouraged physicians to perform double reads of difficult cases, and develop guidelines to ensure this occurs with consistency.

You can read the full report from the Office of the Health and Disability Commissioner here.

Marty Stempniak

Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic. 

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