Radiologist Fails To Provide Services With Reasonable Care And Skill

Deputy Health and Disability Commissioner Deborah James today released a report finding a radiologist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for not providing services with reasonable care and skill.

A woman in her thirties underwent a surveillance CT scan of her chest and abdomen in 2019 by a radiology service contracted by the DHB. The radiologist reported no metastases on the woman’s lungs. As there was no evidence of recurrence, no further imaging was recommended.

However, following a further surveillance CT scan on her chest and abdomen seven months later, the women was diagnosed with colorectal liver metastases in her lung. The report also noted that the lesion could be observed in previous scans, including the scan reported by the previous radiologist. The woman was immediately referred to the Cardio-Thoracic and Oncology Departments at the DHB for further assessment and treatment, and underwent surgery in early 2020.

The nature of radiology reporting is complex, and it is widely accepted that due to perceptual errors, radiologists may from time to time miss what, with hindsight, may be obvious.

While acknowledging the complex nature of radiology reporting, the Deputy Commissioner considered that the woman’s lung lesion should have been detected by the radiologist when he reported the scan earlier in 2019 and therefore found that the radiologist did not provide the woman with services with reasonable care and skill.

The Deputy Commissioner considered that the radiology service had appropriate systems in place to ensure the quality control of its imaging, and did not find the radiology service liable for the radiologist’s breach of the Code.

"I acknowledge that perceptual errors do occur in radiology. However, in this case, there is unanimous agreement that the lung nodule was visible on the earlier CT scan and should have been detected.

"I consider that a radiologist in these circumstances exercising reasonable care and skill would have detected the lung nodule on a scan," said Ms James.

As a healthcare provider, the radiology service is responsible for providing services in accordance with the Code.

"A review of the relevant imaging has found that all of the reports follow standard international or RANZCR guidelines for oncology reports. All of the scans were performed using standard protocols, and the quality of the reports appropriate.

"In this case, I consider that the radiologist’s independent perceptual error did not indicate broader systems or organisational issues at the radiology service and that the radiology service had systems in place to ensure the quality control of its imaging," said Ms James.

Complaints offer a significant learning opportunity, to reflect on how care could be improved - to create positive change for consumers and healthcare providers.

"I am pleased to see that the radiologist has acknowledged the error on his part and has made changes to his practice."

"The radiology service is also instituting a programme to help manage a radiologist’s workload and for image review and interpretation. The programme will incorporate a peer review module, which will require a percentage of all reported studies to be reviewed by another radiologist for quality control purposes," said Ms James.

Ms James recommended that the radiologist continue to implement the changes to his practice as a result of this complaint to ensure that images reconstructed with soft tissue and lung algorithms are compared directly at the time of reporting, and also continue to have a self "second look" to improve accuracy.

Ms James also recommended that this case be used for shared learning for educational purposes (e.g., for discussion in review meetings with colleagues or students), and that the anonymised copy of this report be shared with all of the radiology service’s branches.

The radiologist has provided a written apology to the woman.

The full report of case 19HDC02399 is available on the HDC website.

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