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Negligent assessment and systemic failures

23 October 2018

Ms F, a 28-year-old social smoker with a history of childhood asthma, presented to the Emergency Department (ED) complaining of low central chest pain and mild shortness of breath. She told the attending doctor that she was a non-smoker, despite smoking five cigarettes daily for a ten-year period. A chest x-ray was performed during her assessment, which revealed a nodular opacity in the mid-zone of the right lung. She was treated for an upper respiratory tract infection and discharged with respiratory follow-up.

Two weeks later she was reassessed by consultant respiratory physician Dr K. He repeated the chest x-ray with two views, which he interpreted as normal. Ms F again maintained that she was a non-smoker when asked. Dr K advised Ms F that the nodule seen on the original ED image was likely to have been an inflammatory nodule that had resolved spontaneously. Since she was asymptomatic, he asked her to follow up if she developed further symptoms.

More than three years later, Ms F presented back to the ED, this time with a low-grade fever and right-sided chest pain. The pain was worse on deep inspiration and she felt slightly breathless. Dr A was on duty and requested a chest x-ray, noting again the presence of a right mid-zone nodule. He compared the images to those taken three years earlier and found no change. He discussed the images with his supervising consultant, noting the previous input from a respiratory physician, and diagnosed Ms F with musculoskeletal chest pain. She was advised to return if she felt worse.

The formal report came back the following day, stating the presence of “a rounded opacity measuring 2.2cm in the right mid-zone of the lung which appears stable since the previous x-ray”. A follow-up radiograph was suggested; however, the report was not flagged as abnormal by the radiologist, so was not routed back to the ED for follow up.

Another year passed, and Ms F returned to the same ED, again with chest pain and now complaining of discomfort over her lower left ribs. Dr P, concerned about possible rib fracture, ordered a chest x-ray. No fractures were seen and a diagnosis of costochondritis was made. The right lung nodule was overlooked. The radiologist’s report was completed the following day, noting the right mid-zone nodule, which had increased in size (2.6x2.2cm compared to 2.5x2cm). Follow-up imaging was advised but, once again, the report was not flagged as abnormal to the ED.

Four months on, Ms F visited her GP with a persistent cough, shortness of breath and haemoptysis. She was urgently referred to the respiratory team, who ordered a CT scan. Although the appearance of the nodule was reported as being consistent with a benign pulmonary hamartoma, Ms F underwent biopsy of the nodule, which was found to be malignant. She underwent lobectomy for Stage IIA non-small cell lung cancer but was eventually given a terminal diagnosis.

Claims were brought against the doctors involved in her care. Respiratory consultant Dr K was criticised for failing to identify the nodule on the second x-ray, and failing to arrange adequate follow-up. Although Dr K’s error would probably have amounted to a breach of duty, experts reviewed the series of images and opined that the growth of the nodule was indolent and likely to have been benign when Ms F was first reviewed. Given that there was no change over a two-year period, she would have been discharged without follow-up by Dr K anyway, thus providing Dr K with a potential causation defence.

Dr A in the ED was alleged to have been negligent in his assessment. The claimant stated that the nodule should have been noted and referred directly to a respiratory specialist for further evaluation. However, experts supported the management as appropriate, and confirmed that even if Ms F had been referred, then the prognosis would likely have been the same.

Systemic failures at the hospital were noted and the radiology department was criticised for failing to have an adequate notification system in place to follow-up on abnormal x-rays. The hospital took the position that the individual doctors involved in the care of Ms F should have personally followed up the x-rays they requested.

The case eventually went to trial, where Medical Protection successfully defended the case on behalf of Drs A and K.

Learning points

Patients may not admit to themselves that they are smokers if they ‘only smoke socially’. During respiratory consultations, specific questions about smoking history should be asked and documented.

In the UK, the Royal College of Radiologists standards of practice recommend that radiologists are responsible for flagging reports when an alert is required, but it is the responsibility of the organisation to ensure that failsafe systems are in place to ensure appropriate reporting and follow-up takes place. Failsafe systems are a “safety net” and do not remove responsibility from the referring clinician to ensure that all reports of requested examinations are reviewed and acted upon. If adequate systems are not in place to ensure appropriate reporting and follow-up, doctors should raise concerns in line with local guidance.