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Missed case of ovarian cancer goes to trial

01 October 2019

A 36-year-old woman presented to her GP complaining of a six month history of abdominal bloating and urinary frequency. The GP referred her to a gynaecologist, who assessed the patient and requested a pelvic MRI scan. The scan was reviewed by Dr D, a radiologist, who reported that it was within normal limits with no pathology and that both ovaries were normal.

Over the next few months, the patient continued to experience abdominal pain and bloating.

A few months later, she was referred by her GP to hospital with shortness of breath and right pleuritic chest pain. An x-ray showed bilateral pleural effusions and a right pleural drain was inserted. A few days later, the patient discharged herself against medical advice, but was seen in the clinic a few days later, where a left pleural drain was inserted.

A CT of the thorax, abdomen and pelvis showed a bilateral pleural effusion and bilateral enlarged ovaries. The right ovary was reported as 5cm in size, with a complex appearance, and it was noted that there were multiple enhancing mesenteric/peritoneal nodular deposits. The conclusion was of a suspicious ovarian mass with evidence of peritoneal and omental infiltration.

The cytology from the pleural effusion confirmed the presence of adenocarcinoma cells of gynaecological origin. The patient was diagnosed with stage IV ovarian cancer and given a terminal prognosis.

She brought a claim against the radiologist Dr D, who was a Medical Protection member, alleging that he had failed to detect features of bilateral ovarian cystadenocarcinoma, which had led to a seven-month delay in diagnosis of her condition. An expert radiologist instructed by the claimant reviewed the MRI scans that had been reported by Dr D and considered there was a lobulated septated cystic mass on the right ovary.

Medical Protection obtained expert evidence from a specialist in gynaecological imaging, who was supportive of Dr D’s interpretation of the MRI scan.

The case progressed to a trial.

When giving evidence, the expert radiologist instructed by Medical Protection showed the court a number of slides to assist in its understanding of the clinical situation. The slides showed normal ovaries, abnormal ovaries and finally images of the patient’s ovaries. The expert explained what a radiologist would be looking out for and demonstrated that none of those concerning features were present in the images of the patient’s ovaries.

In addition, the member brought his laptop and connected it to a large screen so he could show the court in real time what his routine practice was when reviewing ovaries, which particular features he would be specifically looking out for, and why he was satisfied there was nothing abnormal in this case.

The trial judge ultimately considered the evidence of the Medical Protection expert to be more convincing.

The judge was very sympathetic to the patient and her family; however, he found in favour of the member and dismissed the patient’s case.

Learning points

  • The case turned on the reporting of the MRI scan – if the court had accepted there were features of ovarian cystadenocarcinoma present on the initial scan then it might have been difficult to defend the case on causation.
  • The primary function of professional medical experts is to provide the court with an independent opinion on the clinical issues involved in a case to help the court make a decision on questions falling within that expert’s specialist field. An expert must assimilate the facts of the case, consider the questions asked of them, and formulate an opinion on the clinical issues based on their experience and qualifications.
  • Where the court is presented with differing expert opinion, it is up to the judge to decide which expert evidence they most agree with, and this may be influenced by a number of factors.
  • In this case, the Medical Protection expert was instructed ‘blind’ without the benefit of the final diagnosis, in contrast to the patient’s expert who was advised of the diagnosis at the time of his instruction.
  • In addition, the Medical Protection expert was still in clinical practice and had a great deal of practical experience reporting on MRI scans in a clinical setting. The patient’s expert was retired and had reported on MRIs for research purposes in the last ten years of his practice.
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