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Failure to appropriately scan and assess thyroid gland (14HDC00558)
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Radiologist ~ Sonographer ~ Thyroid ~ Lymph nodes ~ Cancer ~
Ultrasound ~ Right 4(1)
A woman presented to her general practitioner (GP) having
noticed a lump at the front of the base of her neck on the
right-hand side. Blood tests were normal. The GP referred the woman
for an ultrasound of the right thyroid gland which was performed
the same day at a radiology service by a sonographer.
The local lymph nodes adjacent to the thyroid gland were not
scanned by the sonographer. No comments were recorded by the
sonographer in the designated sonographer worksheet space headed
"lymph nodes". The sonographer did not discuss the ultrasound with
the reporting radiologist.
The radiologist reviewed the ultrasound images together with the
referral form and sonographer worksheet. The radiologist reported
the right thyroid to be slightly bulkier than the left, the
presence of nodules, and a finding suggestive of a multinodular
goitre. No biopsy/fine needle aspiration (FNA) was recommended.
Over the next two years, the woman attended a number of primary
care consultations, some of which related to her concerns about the
lump in her neck. No apparent changes were noted by doctors during
this time. However, owing to her own ongoing concerns, the woman
requested a referral to a consultant.
Investigations performed by the consultant demonstrated that the
nodule of the right lobe of the thyroid, as well as a smaller one
on the left lobe, were very slightly larger than when studied
originally. The consultant referred the woman for an ultrasound and
FNA of the right and left thyroid nodules.
The FNA biopsies of both areas confirmed papillary thyroid
carcinoma in both masses. A CT scan confirmed the presence of the
carcinoma in the thyroid nodule, as well as a right-sided cervical
lymphadenopathy. The woman was referred to a head and neck surgeon,
and subsequently required extensive surgery and radiotherapy.
It was held that the radiologist failed to query the absence of
imaging of the local lymph nodes, to ensure that he had all the
relevant information to make his assessment. Furthermore, he failed
to interpret the scan as showing suspicious findings and to
recommend FNA. Accordingly, the radiologist did not provide
services to the woman with reasonable care and skill and, breached
The sonographer did not follow accepted professional practice
and scan the lymph nodes adjacent to the thyroid gland. The
sonographer failed to provide services to the woman with reasonable
care and skill and breached Right 4(1).
The radiology service's protocol did not explicitly refer to the
need to assess and/or scan lymph nodes adjacent to the thyroid.
Accordingly, the radiology service was aware of the sonographer's
practice to adequately fulfil the minimum requirements of an
examination, but did not take action to ensure that he extended his
examinations, in order to be consistent with accepted practice. The
radiology service failed to provide services to the woman with
reasonable care and skill and breached Right 4(1).
The Commissioner recommended that:
- the Medical Radiation Technologists Board consider taking steps
to ensure that all New Zealand sonographers adopt a consistent
approach to ultrasound scanning of the thyroid;
- the Ministry of Health consider the wording of the national
guidelines for primary care, surrounding indications for FNA in a
patient presenting with a neck lump;
- the sub-regional clinical leadership group consider the clarity
of local DHB guidelines surrounding indications for FNA in a
patient presenting with a neck lump; and
- the radiology service audit compliance with the changes it has
made to its ultrasound protocols to include a requirement for
sonographers to assess and/or scan adjacent lymph nodes when
scanning the thyroid gland.
Recommendations were also made with regard to the radiologist
and the sonographer, including that they each arrange independent
quality reviews of a random selection of thyroid ultrasound scans
and reports they have completed over the last 12 months