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O&G reprimanded over diagnostic error

Monday, 27 February 2023

Key messages from the case

Diagnostic error can occur for many reasons. Doctors must remain vigilant to ensure thorough assessment and to avoid assumptions or omissions. Doctors should document their decision making, including negative findings.

Details of the decision

Ms SM, 55, presented with urgent referral for review of 4 months’ post-menopausal bleeding, severe pelvic pain, ultrasound that identified enlarged uterus, fibroids and no apparent cause for continuous pelvic pain. Ms SM was overdue for a pap smear and could not remember when her last one had been.

Instead of triaging Ms SM as an urgent patient, conducting an examination and arranging urgent diagnostic procedures, Dr G (O&G) obtained consent for a total hysterectomy and placed her on the elective waiting list as a non-urgent patient. She referred Ms SM back to the GP for a pap smear.

About a month later, Ms SM was diagnosed with Stage 4 squamous cell carcinoma of the cervix with widespread metastasis.

Diagnostic Error

No rationale was given for the misdiagnosis.

Despite the error in management, the delay in diagnosis did not negatively impact the outcome for Ms SM.

Professional conduct

When Dr G was made aware of the error, she self-reported to Ahpra. She fully co-operated with the Board’s investigation and in a review of her records. She arranged mentoring and auditing of her records and consented to the imposition of conditions.


The Medical Board and the state tribunal agreed that Dr G’s practice and diagnostic error amounted to unprofessional conduct. She was reprimanded, placed under conditions of mentoring and an audit of her practice, and was ordered to pay legal costs of $12,500.

Key lessons

Even very experienced practitioners can fall into the cognitive mistakes that lead to diagnostic error.

It is always appropriate to check your processes for history taking and diagnosis to ensure that you are really listening to the patient, considering all relevant information, considering a differential diagnosis and not falling into assumptions or cognitive biases that can lead to diagnostic error.

References and further reading

More information

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O&G reprimanded over diagnostic error (PDF)


The case discussed in this publication is based on a real case. Certain information has been de-identified to preserve privacy and confidentiality. The information in this article does not constitute legal advice or other professional advice and should not be relied upon as such. It is intended only to provide a summary and general overview on matters of interest and it is not intended to be comprehensive. You should seek legal or other professional advice before acting or relying on any of its content. 

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