Avant claims data indicates that 60% of diagnostic errors
are related to a missed or delayed diagnosis.
Consider this scenario. You have been treating a 35-year-old
woman for four years. During that time, she has had classic
migraine symptoms, which usually respond to ergotamine
and analgesics. In the last year, the symptoms have been more
frequent and prophylaxis with Deseril has been helpful.
She again presents with the usual symptoms but has noticed
some face numbness and a more frequent pattern of
occurrence. A CT scan shows a 4cm meningioma in the right
temporal area which clearly has been there for a long time.
At some time you may face a similar diagnostic challenge. It
may be less dramatic or more serious. “Could this have been
picked up earlier?” is an obvious question the patient will put
to you – and one which requires an answer. Your response
will set the scene for the ongoing relationship and sometimes
influence how the patient responds to the delay in diagnosis.
Handling the situation
1. Personally tell the patient - Depending on the urgency
of the diagnosis, contact the patient to inform them of
the unexpected finding and its implications. A personal
telephone call to set up a face-to-face conversation is the most
appropriate course, rather than delegation to another member
of the practice.
2. Obtain advice - If necessary, contact a specialist for
advice on the likely treatment required and the impact of the
delayed diagnosis so you are prepared to answer the patient’s
questions when you meet with them.
3. Explain the situation - Have a face-to-face discussion with
your patient about the new findings. Use open disclosure, say
how sorry you are about the unexpected news. Explain what
treatment may be necessary.
4. Arrange management of the patient and immediate
treatment - Preferably, arrange these through a phone
call while the patient is present; do not just give the patient
a referral letter and ask them to arrange the follow-up
5. Maintain contact with the patient - Enquire periodically
about the patient’s progress to help them cope with the
feelings about the diagnosis or any possible delays. Expressions
of personal concern and interest in what has occurred (such
as enquiring about a recent admission to hospital or other
treatment) are part of good ongoing care and will assist in the
ongoing doctor–patient relationship.
6. Offer ongoing care - When the crisis period has passed,
the patient may or may not wish to continue under your care.
If the patient requests referral to a new doctor, facilitate the
transfer and offer to provide the new doctor with the patient’s
7. Consider the cause of the delayed diagnosis - kneejerk
reaction after such an experience would be to overinvestigate
every patient presenting with a headache. It is more
sensible to consider your thoughts and decisions in relation to
the management of the patient and develop objective criteria
for the management of common clinical problems.
8. Review systems - If the delay was caused or contributed
to by a systems error, such as follow-up failure or misfiling of
pathology or X-ray reports, review your systems to prevent
a recurrence. Avant can advise you about current practice
standards for investigation tracking and follow-up systems.
9. Change and inform - We recommend you seek advice from
Avant before taking this step to avoid making any admissions
of liability. Telling the patient about the steps you have taken to
minimise the risk of a repeat of this situation can reassure them
that some learning has come from what happened. This can be
achieved through following open disclosure practices.
10. Notify Avant about the incident - As soon as possible
after you become aware of the incident let Avant know. If
you receive a letter of complaint from the patient or their
representative, do not reply without first obtaining advice from
11. Consider cancelling your fee - Avoid sending accounts
and reminders where these will inflame the situation. It is
better to forego a fee than risk offending the patient. Patients
will often forgive human error but they never forgive error
combined with perceived greed or arrogance. Not sending a
bill is not an admission of liability.
What if another doctor is responsible for the
misdiagnosis and you have made the correct
When discussing the diagnosis and its implications, stick to
the facts. You only have one side of the history and as such,
it is better to avoid any implied or stated criticism about
the doctor(s) who may have been responsible for previous
diagnosis. It is not uncommon for a legal claim or complaint
to be pursued by a patient after throwaway comments by
the second doctor, which were not intended to be a criticism.
Remain professional and objective during these exchanges.
If, at a later date, the patient’s solicitor seeks a report in the
investigation of a compensation claim, keep the report
objective and avoid criticism. Contact Avant if you are
unsure what is required.
As a guide, do what you would expect the other doctor to do
if the roles were reversed. This might include informing the
other doctor of the correct diagnosis and, if the patient agrees,
offering to send the patient back to that doctor so they have
an opportunity to explain.
All too often, the first inkling of an error or patient
dissatisfaction is when a doctor receives a writ or a solicitor’s
“letter before action” which proposes negligence proceedings.
- Consider open disclosure, which would generally include an apology saying, “I am/We are sorry”.
- Refer the patient immediately for urgent treatment,
- Ensure clear documentation of events in the
- Maintain interest in the patient’s progress.
- Avoid sending accounts for incorrect treatment.
- Avoid unnecessary or derogatory comments about
- Notify Avant about adverse incidents and complaints. If
in doubt about whether to notify, contact Avant anyway.