Radiologist blamed after fatal colon cancer case missed by ‘inadequate’ CT report

Health authorities are criticizing a radiologist for an “inadequate” CT report that missed a woman’s case of colon cancer.

The controversy dates back to early 2018, when a New Zealand woman underwent a CT scan of her abdomen and pelvis. The patient had been losing weight for three months and suffering from abdominal pain for two months.

However, radiologist “Dr. B's” report on the CT scan found only two minor problems but no “obvious malignancy.” He recommended a follow-up ultrasound in three months, and the woman was informed by another doctor that her CT scan had shown no obvious problems.

Weeks later, “Ms. A” was readmitted with severe illness. At this time, the radiologist reviewed the CT scan again and noted an abnormality that he had missed. Dr. B updated the document with an addendum stating the finding and the need for further evaluation, but did not document whether this change had been communicated to the original referrer.

Two days later, another doctor noted the addendum, according to the Health & Disability Commissioner, who is responsible for reviewing medical malpractice claims in the country. Doctors conducted another medical examination that day and an MRI scan revealed a cancerous mass that was causing a bowel obstruction. Ms. A died a few weeks later and the coroner referred his concerns about the case to the state regulator.

Following an investigation, Assistant Commissioner Carolyn Cooper found that the radiologist had breached the Code of Conduct with his “inadequate” CT report, which included failing to mention several key anatomical structures in his analysis.

“I find the CT report inadequate because it did not mention the gastrointestinal tract, retroperitoneal structures, or pelvic organs, or whether or not they appeared normal,” Cooper said in an Aug. 12 press release.

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

Radiology department policy stated that a radiologist must notify the referring physician of the results by telephone when creating an addendum that differed from the original finding. Despite this, the hospital's current systems required the radiologist to select an alert outside of the report text in the information system. This was entered into a worklist, from which the administrative team would email the referring physician to notify them of the abnormal finding.

“Based on the information provided to me, I believe Dr B followed the procedures in place at Health NZ,” the inquiry said. “However, I am critical of the alert system and process for documenting addendums. Clear documentation of when and how the addendum was communicated to relevant parties could have prevented confusion in Ms A's treatment and the resulting delay. However, the alert system and process for documentation are not described in Health NZ's policies. Although Health NZ has stated that it is extremely unlikely that a radiologist would fail to notify a relevant clinician when a significant error is identified, I believe that the findings of Health NZ's internal review reflect a systemic problem in relation to the use of the alert system and reporting of addendums.”

Following the incident, the Health and Disability Commissioner recommends a written apology for the deficiencies, conducting an audit of 50 randomly selected X-ray reports, and providing the office with an updated written policy on how to deal with addendums.