Cameron complains of neck pain after a fall. His GP refers him for x-rays. The radiologist, Dr Smith, reports back that the x-ray showed no fracture or dislocation.
Six months later, Cameron comes back with a persistent cough. He’s been coughing up flecks of blood. His GP refers him for an urgent chest x-ray. Dr Wesley, the consultant radiologist, identifies a large mass at the apex of the right lung.
Dr Wesley views Cameron’s earlier x-ray. She notes that the mass is clearly visible, though smaller, at the edge of the film. The mass is confirmed as a primary lung tumour that has metastasised. It is inoperable.
Cameron is distraught by the diagnosis and starts to withdraw from his friends and family. An oncology team takes over Cameron's care. Dr Smith who reported the first x-ray no longer works for the hospital and hasn't left any contact details.
What the doctor did
Dr Wesley spoke to the oncologist, Dr Kyei, in charge of Cameron’s care. They decided that Dr Kyei would be best placed to speak to Cameron as he had developed a good relationship with him. Dr Kyei would also best appreciate the consequences of late diagnosis, the resultant changes in treatment options, side effects and prognosis and be able to offer Cameron the help and support he needs.
Dr Wesley wrote her report objectively. She avoided statements such as the lesion “should” have been seen before or that it was “understandable” that it was not seen and reported.
She tried to locate Dr Smith but was unable to find him. She anonymised the report as appropriate and shared what had happened on READ ( the Royal College of Radiologists’ dedicated system for sharing incidents and discrepancies across the specialty) so other radiologists could learn from the error.
What the doctor had to consider
- Whether there was any point telling the patient what had happened as it wouldn’t change the outcome. However unwelcome the news of an error may be, and even if it’s too late to change the outcome, it would not be acceptable for the doctor, nurse or midwife to withhold that information from the patient. This is particularly true if the error means an opportunity to start treatment earlier was missed
- Whether the patient needed to be told everything. Patients will normally want to know more about what has happened, but you should give patient’s the opportunity not to be given every detail. If the patient does not want more information you should try to find out why (paragraph 12)
- If he had to apologise even though it wasn’t his error? When apologising and explaining what has happened we don’t expect you to take personal responsibility for something that wasn’t your fault (such as system errors or a colleague's mistake). But the patient has a right to an apology from the most appropriate team member, regardless of who or what may be responsible for what has happened (paragraph 15).
- Not everyone involved in a patient’s care has to take responsibility for reporting adverse incidents and speaking to patients if things go wrong. But we do expect professionals covered by the duty (ie doctors, nurses and midwives) to make sure that someone in the team has taken on this responsibility. The most appropriate team member will usually be the lead or accountable clinician. It’s important that the patient’s needs are considered in making this decision (paragraph 9).
- What action should be taken about the radiologist responsible for the error? Ideally the doctor should contact the previous radiologist as soon as practical after discovering the error so that they are aware of it and can reflect on – and adjust – their practice as necessary to reduce the likelihood of it occurring again. However, it will not always be possible to contact the reporter of the previous Xray: since it might have been reported by teleradiology from another part of the UK or abroad.
- Whether the error should be reported. Whether or not contact was made with the radiologist who made the error, the case should be referred, anonymised where possible, to a Learning from Reporting Discrepancies or QA meeting. This is so other radiologists can learn from the event to reduce the chance of it occurring again (paragraphs 22-26)