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Failure to follow up chest X-ray result (12HDC00112)
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District health board ~ Public hospital ~
Consultant radiologist ~ Anaesthetist ~ Pre-anaesthetic assessment
~ Test results ~ Chest X-ray ~ Radiology reporting ~ Red flag ~
Carcinoma ~ Systemic failures ~ Rights 4(1), 4(2)
A woman with a history of heavy smoking was referred by her GP
to the dental unit at a public hospital for removal of all her
teeth. The woman saw a locum dental surgeon who completed a health
questionnaire and operation booking form. A pre-anaesthetic
assessment was requested by the surgeon. The surgeon's
understanding was that any abnormal test findings would be reported
to and acted on by the anaesthetic team.
At the assessment, the anaesthetist recorded the woman's history
and her medications. The anaesthetist examined the woman and noted
that she had a heart murmur. The anaesthetist requested a chest
X-ray and echocardiogram be done before surgery. The anaesthetist
did not document this request, or the woman's smoking history. The
anaesthetist's signature on the X-ray request form was unclear.
The woman had an echocardiogram. The referrer listed on the
echocardiogram report was incorrect, and the report was not copied
to the woman's GP, the surgeon, or the anaesthetist. The next day,
the woman had a chest X-ray reported by a radiologist. The
radiologist reported an abnormal opacity on the lung and
recommended a follow-up investigation. However, the wording of his
report was unclear, and the report was not copied to the woman's
GP. The radiologist was not aware that dental unit X-rays
were not copied to GPs - a DHB practice contrary to other
outpatient X-rays. The radiologist did not follow the process in
place to "red flag" abnormal results electronically.
The woman's abnormal chest X-ray result was automatically faxed
to the dental unit. The referrer listed on the report was a generic
"Dr Dental Dental" rather than a specific surgeon. No one in the
unit sighted the results of the woman's chest X-ray, and staff did
not put the results in the woman's health record. Neither the
surgeon's nor the anaesthetist's name appeared on the woman's X-ray
report, and it was not copied to the surgeon, the anaesthetist, or
A second anaesthetist, scheduled to provide anaesthesia prior to
surgery, saw the woman in the surgical day unit. He checked her
medical history and went through the first anaesthetist's
preoperative assessment notes, but did not review her heart murmur.
The DHB could not confirm whether the X-ray report accompanied the
woman to theatre. Surgery went ahead, and the woman was discharged
A year later, the woman visited a locum general practitioner
owing to chest pain. A chest X-ray showed an upper lobe lung mass.
Subsequent investigations confirmed this to be an inoperable
carcinoma with metastases. DHB staff met with the woman to explain
what had happened and apologise. Sadly, the woman died later that
year. The DHB completed a Root Cause Analysis Report, made
recommendations, and instigated changes to improve services.
The failure to follow up the abnormality identified on the
woman's chest X-ray occurred in the context of a number of serious
organisational and systemic failures on the part of the DHB.
Primarily, if the DHB process in place at the time meant that
responsibility for following up the X-ray did not lie with the
clinician ordering the test, there should have been an explicit and
documented process that provided clarity and identified the
clinician who would be responsible for reviewing and
following up the test. An effective and formalised system was not
in place for reporting test results. Accordingly, the DHB did not
provide services to the woman with reasonable care and skill and
breached Right 4(1).
Adverse comment was made about the first anaesthetist's
deficiencies in documentation. Relevant clinical information and
the nature of investigations ordered were not brought to the
attention of the second anaesthetist who would be administering
anaesthesia on the day of surgery.
The radiologist's reporting of the chest X-ray was unclear. An
opportunity for the woman's abnormal chest X-ray result to be
brought to the attention of clinicians caring for the woman was
lost when the radiologist failed to "red flag" the electronic
system. The radiologist did not provide services with reasonable
care and skill and, therefore, breached Right 4(1).
The second anaesthetist's preoperative assessment did not comply
fully with professional standards, as he did not address all the
elements that were identified in the first anaesthetist's
pre-anaesthetic assessment, most notably the woman's heart murmur.
Accordingly, the second anaesthetist breached Right 4(2). Detailed
recommendations were made to the DHB, to be attended to as a matter