Radiologist Fails To Identify Important Information On CT Scan

Health and Disability Commissioner Morag McDowell today released a report finding a radiologist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for their failure to identify information in a scan.

The man, aged in his eighties, had a CT scan at a public hospital to investigate abdominal pain and diarrhoea he was experiencing.

The scan showed he had free gas in his abdominal cavity which indicated a bowel perforation. However, the radiologist missed this in the scan report and the man was discharged from hospital. Sadly, a few days later he died as a result of septic shock due to the unrecognised bowel perforation.

As a result of the radiologist’s failure to identify free gas in the abdomen on the CT scan, the opportunity to consider surgical review and treatment options was missed.

The Commissioner was critical that the radiologist did not identify and describe the free abdominal gas on the scan. She considered the omission to be an individual error, with no contributing systemic or other issues.

"The report highlights the importance of radiologists identifying significant findings on CT scans," Ms McDowell said.

She recommended that the radiology service provide an update on the level of internal audit of its radiologists, and the radiologist provide a written apology to the man’s family. She noted that the radiologist has reflected on these events and has completed appropriate training and audits of abdominal scan reporting.

The full report on case 19HDC01991 is available on the HDC website.

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