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Lesion missed on X-ray (14HDC01066)
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(14HDC01066, 5 August 2016)
Radiologist ~ Radiology service ~ X-ray ~Lytic lesion
~ Bone destruction ~ Missed diagnosis ~ Right 4(1)
An older woman presented to her general practitioner (GP) with a
10-day history of severe pain in her lower back and hips. The GP
referred the woman for a lumbar spine (lower back) X-ray. The X-ray
was reported by a radiologist at a private radiology service. The
radiologist identified multilevel chronic disc degeneration, but
did not detect an L2 lytic lesion.
At the time of the events, the radiology service was
understaffed, and the radiologist had an injury which slowed down
the speed of his work. The radiology service attempted to arrange a
work place assessment for the radiologist, but, in the interim, his
workload remained the same.
The woman continued to experience pain, and her mobility
decreased. She sought assistance from a number of different
services over the next eight months and was subsequently
admitted to the local hospital. An X-ray and magnetic resonance
imaging identified an L2 lytic lesion, as well as significant
spinal cord compression. The woman was transferred to a larger
public hospital where she was diagnosed with multiple myeloma
(cancer of plasma cells) and underwent spinal stabilisation
surgery. Her recovery was difficult, and she was transferred back
to the local hospital. The woman developed hospital-acquired
pneumonia, and her condition began to deteriorate. She died a short
It was held that the radiologist did not provide services to the
woman with reasonable care and skill, as he failed to identify an
L2 lytic lesion on the woman's X-ray. Accordingly, he breached
Adverse comment is made that, at the time of these events, the
radiology service was understaffed in that it did not have a
sufficient number of radiologists working. Adverse comment is also
made that, although the radiology service attempted to arrange a
work place assessment with regard to the radiologist's injury,
nothing more was done in the interim to ensure that the radiologist
could continue to carry out his work appropriately.
The care the woman received from the local DHB was appropriate
in the circumstances.
It was recommended that the radiologist have an independent
radiologist peer perform a review of a random selection of his
reports completed in the last 12 months, and that he provide a
written apology to the woman's husband.
It was recommended that the radiology service review the
effectiveness of the changes it has made as a result of this case.
This includes an update on the progress of the radiology service's
plans to decrease interruptions to radiologists from technicians
for advice, by reviewing its computed tomography (CT) and magnetic
resonance imaging (MRI) protocols, and to reduce the time
radiologists need to spend on vetting referral requests, by
considering changing this to an electronic process.