A delay in the diagnosis of a patient’s cancer due to a missed x-ray result
emphasises the importance of keeping track of patient results and robust clinical
Missed x-ray report
The patient was a life-long smoker and had been referred to
a cardiologist member for management of atrial fibrillation. The doctor had
treated the patient for a number of years. After trialling medication
unsuccessfully, the cardiologist performed pacemaker implantation and atrioventricular
(AV) node ablation.
In accordance with their usual practice, the cardiologist ordered
a chest x-ray the day after the procedure to exclude any device-related
complications, such as pneumothorax. The cardiologist would usually receive a
call from nursing staff relaying the x-ray results. However, on this occasion, the
doctor did not recall receiving or reading the report, or whether the results
were relayed to them over the phone. The x-ray report was not actioned at the
The x-ray report referred to a possible lung nodule and
recommended referral for a CT scan.
The lung nodule was eventually discovered over two years
later as an incidental finding on a CT coronary angiogram that was performed to
exclude ischaemic heart disease, and was found to be malignant. This culminated
in a two-and-a-half-year delay in diagnosing the cancer. Subsequently, the patient
brought a medical negligence claim against the cardiologist.
The cardiologist was understandably devastated and contacted
Avant immediately. One of our Senior Medical Advisors was able to provide invaluable
collegial and emotional support to the member throughout the process.
Ultimately, the civil claim was resolved early in an
out-of-court settlement. The claim allowed the member to reflect on their practice
and they now check on all of their patients’ results personally.
While the claim did not impact the doctor’s ability to practise,
they described the experience as extremely distressing and said it profoundly rocked
their confidence both personally and professionally.
Impressed by the professionalism of Avant’s medico-legal
team, the member said the Medical Advisor provided all the peer support they needed
throughout the process.
‘Thank you so much. I really appreciate the support and
advice I received from Avant’s Medical Advisor and the medico-legal team during
this time. The professionalism of Avant is wonderful,’ the member said.
Tracking and actioning
case drives home the importance of having a reliable
system for dealing with tests and results to support both doctors and practice
staff in providing optimal patient care and management.
Your practice or hospital needs to
ensure test results are tracked, monitored, communicated to patients and the relevant
doctors notified and appropriate recall actions are taken. There should be a
centralised system in place for tracking tests and actioning clinically significant
tests and results. This should be designed in a way that anticipates that
individual cases will require different levels of follow up depending on the
clinical significance of the test and/or results.
As a doctor, it’s important when you recommend a test to a patient
that you advise them of the reasons for the test, the importance of having it
done, arrangements for obtaining the result, and the potential consequences of
not having the test. For more information, read our article
on tracking clinically significant tests.
Good clinical record
The case also highlights that good clinical record keeping is
- for good patient care
- for a proper
defence in the event of a claim or complaint against you.
information, download our factsheet, Medical records – the essentials.
Dealing with adverse events
Doctors can suffer extreme levels
of stress and anxiety when something goes wrong, so looking
after yourself after an incident is vital. We
outline steps you can take to look after your wellbeing and the open
If you are subject to a complaint,
contact our Medico-legal Advisory Service (MLAS) on 1800 128 268 for medico-legal advice and support,
available 24 hours a day, seven days a week in emergencies.
You can also refer to our new handbook for
information on how to deal with complaints and obtain CPD points.
Share your view
We welcome your feedback on this article – email the Editor at: firstname.lastname@example.org