Failures in communication of radiology results lead to severe consequences

25 September 2023

A recent Prevention of Future Death (PFD) report from a City of London Coroner, raises concerns about the process of communicating and escalating of radiology results. Shoosmiths’ serious injury lawyers are acting for clients in two cases where delays in reporting or escalating results, and failure to deliver results to clinicians have resulted in serious health consequences.

The City of London Coroner’s PFD report followed the inquest into the death of Peter Harris. Mr Harris had two separate scans over an eighteen-month period, which showed possible evidence of lung cancer, but the result of the first scan was not escalated or shown to any clinician, and the result of the second scan was not reported on for several weeks, resulting in a delay in Mr Harris receiving treatment for cancer.

In her report, the coroner highlighted concerns about the system in place for ‘the communication of concerning radiological findings’, despite steps taken by the Trust to improve the system. She also drew attention to potential weaknesses in a new electronic system being implemented by the Trust which is intended to ‘red-flag’ unexpected cancers and other critical findings in radiology reports. 

The issues in reporting results are worryingly similar in the cases of our clients, leading us to question whether current processes and guidelines need to be reviewed and updated.

Delay in treatment of a lung infection

We are dealing with a claim for a lady who attended her GP on three occasions over a five-day period complaining of chest spasms, cramps, pain in her back, and abdominal pain. She was prescribed analgesia and was referred for a chest x-ray. The x-ray showed  she had a collapsed lung and fluid on the lung. As a malignancy could not be excluded, a CT scan was planned. 

The CT scan was undertaken within two weeks of the request and confirmed that our client had a pleural effusion with loculation (fluid on the lung). Unfortunately, however, the scan was not reported on promptly and the radiologist did not recommend an urgent referral for further investigation, nor did they escalate or ensure urgent communication of the report back to the referring clinician.

In the interim, our client was treated by her GP with courses of antibiotics for a productive cough and was referred to the chest clinic. However, due to increasing symptoms our client went back to her GP who referred her to A&E, where a chest x-ray showed findings consistent with an infection and she was admitted to hospital. 

Our case is that the radiologist’s failure to issue an accurate and timely report was a breach of duty and resulted in our client’s symptoms deteriorating, treatment being delayed and her subsequently requiring surgery.

Failure to report results of a cardiac MRI

We are also acting for another claimant, who presented to his GP with dizziness and a slow heart rate. An ECG was performed, and he was referred to the defendant hospital.

Two months later, the claimant had a consultation with a cardiologist, who reviewed his ECG and advised he had a slow heartbeat. The cardiologist arranged a further ECG, which identified that the left ventricle (the heart's main pumping chamber) was enlarged; this can affect the heart's ability to pump enough oxygen-rich blood to the rest of the body and can be dangerous or fatal.

A further consultation was arranged to discuss the results and an MRI scan was arranged for a few months' time. The MRI report revealed that the left ventricle of the heart was weak. The radiology report was not sent to the cardiologist following the MRI scan, and no follow up appointment was arranged. 

The following year, our client suffered a cardiac arrest and received CPR. He was rushed to the defendant hospital and admitted into the intensive care unit.

Sarah Cunliffe, an expert in Shoosmiths serious injury Team commented: “Looking at these cases, there appears to be a recurring pattern of failure in radiology reporting. Delays and gaps in reporting are extremely worrying. We hope that as a result of these cases the NHS and The Royal College of Radiologists find a way to ensure that the reporting process is robust and that guidelines are clear for all.”



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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