Good records absolve radiologist in complaint
Sunday, 10 April 2022
A case where a radiologist was part of the care team involved in a missed diagnosis complaint underlines the importance of having detailed medical records and communicating significant findings directly to the treating team as soon as possible.
Avant’s data insights show that although claims and complaints against radiologists are fairly infrequent, the majority (66%) are related to diagnosis issues.
In this case, a patient presented to the emergency department with significant back pain and bilateral leg weakness, being unable to weight-bear due to pain. The patient then developed intermittent numbness in the perianal area and urinary incontinence. An MRI was ordered late at night and the radiologist member was asked to review the scans for a possible diagnosis of cauda equina syndrome.
Radiologist flags findings
The radiologist concluded there was disproportionate moderate narrowing in the calibre of the thecal sac with crowding and clumping of the nerve roots, while the posterior epidural fat space was not effaced. He concluded this was probably due to lipomatosis, rather than focal adhesive arachnoiditis. He identified six key images for the referring clinicians, which demonstrated the disc herniations with the crowding of the cauda equina nerve roots clearly visible, using arrows to highlight the areas of concern.
The radiologist immediately contacted the on-call ED consultant, waking him in the middle of the night to communicate the results. The consultant said he would review the scans and examine the patient in the morning. The discussion the radiologist had with the ED consultant about the findings was noted on the report.
Shortly afterwards, the radiologist was called by the ED registrar who had noted the discussion between the radiologist and consultant referenced in the report. The radiologist explained his findings and the consultant’s plan to review the images and patient. The radiologist was not involved any further in the patient’s treatment and did not hear anything more from the ED doctors.
After learning of the MRI results, the ED doctors noted there was no evidence of cauda equina syndrome. The patient was discharged from hospital by the care team the following day. A few days later, the patient presented to a different hospital with persisting symptoms. The patient was diagnosed with cauda equina syndrome and underwent surgery.
Allegations of missed diagnosis
Cauda equina syndrome is a rare but serious condition. If patients do not seek immediate treatment it can result in a range of neurological and physical problems, including paralysis.
The patient’s mother made a complaint to Ahpra alleging that her son’s diagnosis was missed by the treating team and that he should not have been discharged.
An investigation took place. The radiologist was identified as a practitioner involved in the patient’s care, and he sought our support. The other doctors involved in the complaint were not Avant members.
How we helped
We liaised with Ahpra on behalf of the radiologist and obtained an extension of time to provide a comprehensive and considered response to the regulator. We conferred with the radiologist and assisted him to draft a response to the complaint, which was submitted to Ahpra.
Ahpra opted to obtain an independent expert opinion, given the complexity of the medical issues involved. The expert confirmed the radiologist had correctly interpreted the films and provided a timely report in an emergency situation. The expert expressed the view that identifying a moderate central canal stenosis at L3/4 should have been sufficient for the treating team to diagnose cauda equina syndrome if supported by the clinical presentation, and to then refer the patient to the relevant surgical team for further management.
Our team provided a further submission to Ahpra noting that cauda equina syndrome was a clinical diagnosis and would not be made by a radiologist. We argued that the radiologist’s report and the timely steps he took to communicate the significant findings to the treating team were appropriate and to the standard expected of a radiologist practising in Australia.
The Medical Board of Australia accepted our submission and the complaint was closed without any further action against the radiologist.
Evidence of phone discussion
This case highlights that it is often not the role of a radiologist to make a clinical diagnosis, but rather, to interpret the images and report them in a timely fashion.
In this case, the expert evidence supported the radiologist’s interpretation of the images and the report. The expert was particularly supportive of the fact that the radiologist had escalated concerns about the significant findings to the ED consultant in the middle of the night. While it will not always be appropriate to include details of telephone discussions with requesting clinicians in a radiology report, such conversations should be documented in the records.
- Significant and time critical results should be communicated directly to the treating team.
- Medical records should convey enough information to ensure the safe and effective ongoing care of the patient.
- Good record keeping makes complaints easier to address and defend.
- Factsheet: Medical records: the essentials
- Factsheet: Missed or delayed diagnosis
- Factsheet: Medical record-keeping in claims
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