Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person actual name.
Complaint
A man underwent a left hindquarter amputation for the removal of an aggressive tumour (chondrosarcoma) in June 2003. In September 2003 he had further X-rays taken, and in October a CT scan was performed.
In December 2003 the man was admitted to hospital with an acute onset of chest pain. In order to exclude the possibility of a malignant disease process, a CT scan was performed two days after his admission.
On the basis of the report of the CT scan, performed by radiologist Dr B, the patient was discharged home with a diagnosis of "probable musculoskeletal chest pain".
In February 2004 the patient attended his general practitioner, and a chest X-ray was performed. This indicated that pulmonary metastases were present, and were visible in the CT scans of October and December of the previous year.
The Commissioner considered that Dr B had been imprecise in the wording of his report of the CT scan of December 2003, and should have reviewed previous films when he wrote his report. However, these lapses did not warrant a finding that the Code had been breached. Dr B reviewed his practice and apologised to the patient.
30 August 2005
Dear Dr B
Complaint: Mr A
Our ref: 04/00031
Thank you for your response, via your legal representative, to my provisional opinion on Mr A's complaint about the standard of your care.
As you are aware, I obtained independent medical advice from Dr Peter Gendall, radiologist. As part of your response to my provisional opinion, you provided a report from Dr C, who considered that you had provided an appropriate standard of care. In the presence of conflicting reports from Dr Gendall and Dr C, I decided to obtain further advice from Dr Charitha Fernando, radiologist, and I attach his advice.
Having carefully reviewed the information obtained, and considered the advice from Drs Gendall and Fernando, and the reports from Dr C, I have decided that although I have concerns about some aspects of the care you provided to Mr A, a finding that you breached the Code of Health and Disability Services Consumers' Rights is not warranted.
Consequently, I have decided to exercise my discretion under section 37(2) of the Health and Disability Commissioner Act 1994 to take no further action on Mr A's complaint. Set out below are the reasons for my decision. (Much of the information, to page four, is largely unchanged from my provisional opinion.)
The issue identified for investigation was:
Whether Dr B, radiologist, provided services of an appropriate standard to Mr A. In particular, the interpretation and reporting of a chest and upper abdomen CT scan performed on 5 December 2003.
During the course of my investigation I reviewed information from you, a District Health Board (the DHB), a public hospital, Dr D, Dr E, Dr F, and Mr A. I received independent expert medical advice from Dr Peter Gendall and Dr Charitha Fernando, radiologists. I attach Dr Fernando's report, having previously forwarded Dr Gendall's advice.
Summary of facts
On 23 June 2003, Mr A underwent a left hindquarter amputation for the removal of an aggressive chondrosarcoma. The operation was performed by Dr D, orthopaedic surgeon.
On 30 September 2003, Mr A was reviewed at a medical centre by Dr D. He noted that Mr A was using his hindquarter prosthesis in a limited manner at home. Dr D ordered X-rays imaging Mr A's chest and pelvis; the X-ray of Mr A's pelvis revealed the hindquarter amputation with no other abnormality, while that of his chest identified a nodular density in the lower left lobe of the lung. The relevant X-ray report reads: "[the nodular density] may reflect a pulmonary metastasis. This could be confirmed with a CT scan of the chest."
At Dr D's request, a rehabilitation physician ordered a CT scan imaging Mr A's chest. The CT scan was performed on 23 October 2003, and the films read by Dr E, radiologist.
On the night of 3 December 2003, Mr A experienced the onset of acute pain in the lateral flank of his left chest wall. He was subsequently reviewed and admitted to a second public hospital.
On examination, Mr A was found to have left chest tenderness localized to an area the size of a 20 cent coin. Notes received from the second public hospital read: "CXR [chest X-ray] nodular shadow overlying 3rd rib (approximately corresponds to area of tenderness)." Notes also read: "? Local rib lesion ? metastatic deposit (H/O chondrosarcoma + opaque lesion on X-ray)." In order to investigate the possibility that Mr A's pain related to metastatic disease, he underwent a CT and bone scan on 5 December 2003.
The radiology request forms in relation to these scans, both dated 4 December 2003, read: "Grade III Chondrosarcoma - left hemipelvectomy June 03, presents with left chest wall pain on inspiration + movemt, CXR-coin lesion 3rd rib ? metastatic deposits … ordering [by two doctors]."
You read the CT scan performed on 5 December 2003. Your report stated:
"Unfortunately the previous studies are not available for comparison, but based on previous reports the lesion within the left lower lobe appears unchanged, but is non-specific in appearance. The opacity within the lingula may account for the chest X-ray findings but once again, this chest X-ray is not available for comparison
Clinical indication: Grade III chondrosarcoma requiring left hemipelvectomy. Presents with left chest wall pain on inspiration and movement. Chest X-ray coin lesion third rib. ?metastases. Technique: A standard contrast enhanced chest and upper abdominal protocol. Findings: There is no mediastinal or axillary lymphadenopathy. Within the lingula there is some thickening of the interlobular septae with a tubular area of ground-glass opacity which may represent a bronchocoele. A nodular mass within the posterior basal segment of the left lower lobe measures up to 3 x 1.8cm in diameter with no associated air bronchograms or cavitation. There is right basal atelectasis. No pulmonary nodules are seen elsewhere. There is a fatty liver with no focal intrahepatic mass identified. The adrenal glands are unremarkable. No obvious skeletal metastases are identified and there are no chest wall deposits seen."
Mr A also had a bone scan, and the summary of the report stated "No convincing evidence of bony metastatic disease".
Mr A was discharged from hospital on 5 December 2003. The discharge summary, copied to Mr A's general practitioner and to Mr A, stated:
"[Chest X-ray]: nodular shadow overlying [left] 3rd rib - ?metastases
Bone scan negative, no indications malignancy
CT scan negative.
Impression: probable musculoskeletal chest pain."
Dr D, in a letter to ACC dated 9 January 2004, stated:
"[Mr A] had a CT scan of his chest [23 October 2003] performed in [the second public hospital]. This showed no evidence of pulmonary metastatic disease.
[Mr A] was due to have a follow-up appointment in December of 2003 to see me once again. This appointment was deferred as [Mr A] was admitted to [the second public hospital]. He has had a subsequent follow-up appointment made to see me on the 3rd of February 2004 at which time he will have a repeat chest X-ray PA and lateral and an X-ray of his pelvis as follow-up of his tumour."
On 3 February 2004, Mr A consulted Dr D at the medical centre. A report written in respect of a chest X-ray performed the same day reads: "Since September of last year two focal nodular regions have developed in the mid and lower zones of the left lung. These may represent a pulmonary metastasis. Further assessment with CT is suggested."
Accordingly, Dr D requested Mr A's radiological information from the second public hospital. On reviewing the information obtained, Dr D wrote on 12 February 2004 to Mr A. Dr D stated:
"We managed to retrieve your X-rays and CT scans from [the second public hospital] and I have been able to view them together with the radiologist [Dr C] today. I note that the CT scans performed in October of 2003 and December of 2003 are both of your chest. There are indeed lesions which are enlarging in your chest in both the right and left lungs which are consistent with metastatic disease. This finding is obviously not good news. This is not a situation which is amenable to surgical resection of the lesions in your chest particularly at this early stage so soon after your pelvic surgery … I am very sorry to say I have nothing really to offer you in the way of any curative treatment for these lesions. It is likely that they will continue to enlarge and it is also likely that further metastases will appear in your lungs. How long this process will take is guess work. From my experience however it is unusual for patients to survive beyond two years once they develop these chest metastases."
As you are aware, since releasing my provisional opinion Mr A has died.
Expert advice
Dr Peter Gendall
In his first report, Dr Gendall stated that your report on the CT scan of 5 December 2003 was inappropriate and inadequate as you failed to consider the earlier CT scan from 23 October 2003, and also failed to provide an appropriate report in light of the abnormalities on the CT scan and the changes since the scan in October. I have considered carefully your comments written in response to Dr Gendall's report, and Dr Gendall's further report. Dr Gendall did not alter his view and stated that he very quickly formed the opinion that Mr A had multiple lung metastases. This was not clearly identified in your report, and Dr Gendall's advice is that you therefore did not provide an appropriate standard of care.
Dr C
Dr C, the expert briefed by your barrister, considered that you provided an "appropriate and adequate report". In relation to the abnormality in the left lower lobe, Dr C stated that "the masses in the left lower lobe are very suggestive of metastases" but he felt that having described it, and "circle[d] it for emphasis", you had drawn attention to what could be a metastatic deposit. Dr C stated, "It seems quite obvious to me that he is pointing out a lesion that may well be metastatic."
Dr Charitha Fernando
As described above, I decided to obtain further expert advice from Dr Fernando, a radiologist on my panel of independent advisors. Dr Fernando reviewed the CT scan of 5 December 2003 without having available previous radiology studies or reports, and without knowledge of Mr A's complaint, or subsequent clinical outcome.
Dr Fernando considered that your report was "adequate and appropriate", and stated that your desciption of a nodular mass implied that it could be metastases. However, Dr Fernando considered that the abnormality, which you suggested as benign (bronchocoele), was in the context of the clinical picture suspicious of being a tumour.
Dr Fernando also refers to pleural thickening which could have been due to metastases.
My decision
Radiology report
Although Dr Fernando and Dr C have considered that your report was adequate and appropriate, Dr Gendall did not. In my opinion the possible lung metastases perceived by my experts were not clearly reported by you. Dr Fernando has commented that your report implied metastases (a view shared by Dr C), but I consider that your use of language (if you had intended to indicate the possibility of metastases) was insufficiently clear. Dr Gendall called your language "imprecise", and I agree with him. Indeed, I note Dr C's report dated 30 June 2005, where he stated, "The masses in the left lower lobe are very suggestive of metastases", yet your report was not as clear.
Although I accept that you cannot be held totally responsible for the interpretation of your report by the physicians who discharged Mr A on 5 December 2003, their reading of your report was that the CT scan showed no signs of malignancy, and the chest pain was considered to be muskuloskeletal.
Review of previous studies
Dr Gendall stated that you should have issued an interim report until you had been able to review the previous studies for comparison. I accept without reservation the point, made in the DHB's response to my provisional decision that the actual retrieval of these films would be performed by the clerical staff, and it is not a radiologist's job to track them down. However, I agree with Dr Gendall that you should have ordered these previous studies to be retrieved, and should not have issued your final report until you had made comparison with these previous studies. In your letter dated 6 November 2004, once you had reviewed previous CT scans, you stated:
"On retrospective comparison the left lower lobe lesion has increased in size from the previous CTs making this suspicious for metastatic disease given the clinical history of resected chondrosarcoma."
As you are well aware, a radiologist reviews previous films precisely for the reasons of retrospective comparison. Had you reviewed the previous CT scans when making your final report on the CT scan of 5 December 2003 (as was your usual practice, as stated in your letter dated 6 November 2004), you would have seen the increase in size of the abnormality, having compared it with the previous studies. Consequently, your report would have been written, and thus interpreted, differently.
Summary
Having considered the views of Dr Gendall, Dr Fernando and Dr C, although I believe that the care you provided to Mr A was in some respects suboptimal, I do not consider that it warrants a finding that you breached the Code.
I have also taken note of the comments in your letter of 18 March 2005 to HDC's Investigations Manager, where you stated:
"I have reflected upon my actions in view of the complaint and do not take this complaint lightly. … I have always considered the impact of my work in medicine on peoples' lives and approach it from the view of 'what would I want done for my family or if I was the patient' in conjunction with the patient's rights."
I believe that it is important to state that I accept that even had you reported the CT scan to a standard aceptable to Dr Gendall, it is unlikely to have altered Mr A's prognosis. I note that Dr D informed Mr A on 12 February 2004 that there was no surgery that could be offered "so soon after [his] pelvic surgery".
Thank you for your cooperation. The file is now closed.
Yours sincerely
Ron Paterson
Health and Disability Commissioner
Enc
Radiology Advice - Dr Charitha Fernando
I have been asked to provide an opinion to the Commissioner on Case 04/00031 and have read and agree to follow the Commissioner's guidelines for Independent Advisers. I am a General Radiologist with special interest and training in Interventional Radiology, Hepato-biliary Radiology and Abdominal Imaging. I report CT scans of the chest as part of my general reporting. I have been asked to provide independent medical advice as follows:
Purpose
To provide independent expert advice about whether [Dr B] provided an appropriate standard of care to [Mr A].
Background
[Mr A] was admitted by the medical team at [the second public hospital] on 4 December 2003 and a CT scan of the chest and upper abdomen was requested:
"Grade III Chrondrosarcoma - left hemipelvectomy June 2003, presents with left chest wall pain on inspiration + movement, CXR - coin lesion 3rd rib ?metastatic deposits."
The CT scan was reported by [Dr B] on 5 December:
"Unfortunately the previous studies are not available for comparison, but based on previous reports the lesion within the left lower lobe appears unchanged, but is non-specific in appearance. The opacity within the lingula may account for the chest X-ray findings but once again, this chest X-ray is not available for comparison
Clinical indication: Grade III chondrosarcoma requiring left hemipelvectomy. Presents with left chest wall pain on inspiration and movement. Chest X-ray coin lesion third rib. ?metastases. Technique: A standard contrast enhanced chest and upper abdominal protocol. Findings: There is no mediastinal or axillary lymphadenopathy. Within the lingula there is some thickening of the interlobular septae with a tubular area of ground-glass opacity which may represent a bronchocoele. A nodular mass within the posterior basal segment of the left lower lobe measures up to 3 x 1.8cm in diameter with no associated air bronchograms or cavitation. There is right basal atelectasis. No pulmonary nodules are seen elsewhere. There is a fatty liver with no focal intrahepatic mass identified. The adrenal glands are unremarkable. No obvious skeletal metastases are identified and there are no chest wall deposits seen."
Supporting Information
Request form dated 4 December 2003.
CT scan dated 5 December 2003.
CT scan report dated 5 December 2003.
Expert Advice Required
Please review the enclosed CT scan and consider [Dr B's] report.
1. Was [Dr B's] report adequate and appropriate? Please give reasons for your view.
2. Are there any aspects of the care provided by [Dr B] that you consider warrant additional comment?
If in answering the above questions you believe that [Dr B] did not provide an appropriate standard of care, please indicate the severity of the departure from the standards.
To assist you on this last point, I note that some experts approach the question by considering whether the providers' peers would view the conduct with mild, moderate or severe disapproval.
In addition to the specific request for independent medical advice as above I have also received the guidelines for Independent Advisers, your covering letter dated 29 July 2005, copy of the CT. Chest and Upper Abdomen report on 05 Dec 03, request for that CT examination and seven sheets of copy CT films which include window and level settings appropriate for evaluation of the mediastinum and soft tissues and settings appropriate for the evaluation of the lungs.
I do not have the prior chest x-ray or other previous studies alluded to by [Dr B] in his report or the report of these examinations. I do not know if [Dr B] reported these films on a P.A.C.S. system or hard copy films and whether setting for ideal assessment of bones was available.
At this stage I am not aware of the nature of [Mr A's] complaint, his subsequent clinical course or subsequent radiological findings.
In answer to your first question it is my opinion that [Dr B's] report was adequate and appropriate. In saying this I agree with his comments that "There is no axillary or mediastinal lymphadenopathy". [Dr B] has drawn attention to a "nodular mass within the posterior basal segment of the left lower lobe" and indicated that this lesion is "non-specific", with the implication that it could be a metastases.
He has also drawn attention to a second abnormality within the lingula.
[Dr B] has suggested that this may be benign: he states "which may represent a bronchocoele". In the clinical context I am suspicious that this may be due to metastatic tumor. He has however flagged this for the report reader's attention.
The CT does show minor findings not mentioned in [Dr B's] report. These are small areas of pulmonary atelectasis in the lungs and minor possible dilatation of bile ducts in the liver. I do not think those findings are material, and it is reasonable not to discuss them.
There is however also some thickening of the pleura, (that is the outer covering of the lung) and adjacent chest wall musculature on the left side. This is seen as an area of asymmetric (a difference between the left and the right side) thickening involving the left chest wall muscles. This is evident on Images 24 and 25 on the mediastinal windows.
In the clinical context of a patient with a tumour this could be due to a metastasis.
The finding may be relevant as an explanation for left chest wall pain and I note that the clinical requisition states "presents with left chest wall pain on inspiration and movement". My reason for saying that [Dr B's] report is adequate and appropriate is that I believe that even with the clinical information many radiologists would miss what is a subtle abnormality. Without the clinical information I am confident that most radiologists would miss this abnormality.
In summary then in response to your first question I believe that Dr B's report is adequate and appropriate. With respect to your second question Dr B could have identified the left chest wall abnormality as a possible cause of chest pain. However I believe this abnormality to be subtle and of uncertain significance, which many radiologists would not have commented on.
Without knowledge of the nature of the complaint and subsequent clinical course it is not possible to assess the significance of prior imaging studies or reports, which I have not seen.
Please do not hesitate to contact me if these are issues which I have not addressed or if I can assist further. I have retained your enclosures in the meantime.
Charitha Fernando
Radiologist