Articles and Case Studies

Policies need priority

25 Feb 2020

Dr Jane Deacon

by Dr Jane Deacon

Doctor on phone looking at medical imaging

Having policies and protocol in place to manage unexpected test results is paramount

The case

Mrs Simpson1 a 69-year-old woman, presented to her General Practitioner, Dr Lim, for a routine appointment on 2 February 2010. She had a complex medical history which included type ll diabetes, hypertension, rheumatoid arthritis, chronic airways disease and was also a known smoker. At the appointment, Mrs Simpson reported a two-week history of slurred speech. Dr Lim ordered a CT scan which was performed on 11 February 2010.

The initial CT scan (non-contrast) showed an abnormality. On the advice of the radiologist, the radiographer performed a second scan with contrast. The radiologist reported on the scans about an hour after Mrs Simpson left the radiology practice. The scans indicated a mass on the left of the pons which was either a haemorrhage or hypercellular tumour. The radiologist notified Dr Lim by phone, advising that the findings were more likely a haemorrhage and the patient required neurological follow-up. The written report did not include any information which may have indicated the urgency of follow-up.

Dr Lim’s records of the call from the radiologist indicate he understood the imperative for follow-up. His staff attempted on 14 occasions to contact Mrs Simpson on the day after the CT scan, without success. However, no attempt was made over the weekend or Monday to contact Mrs Simpson and only one attempt was made after she failed to attend her appointment booked for 16 February 2010. Mrs Simpson was found deceased at her home on 17 February 2010.

At the inquest into her death, the Coroner was critical of Dr Lim for failing to follow up. He did, however, commend the radiology practice on implementing a policy to deal with similar situations.

Medico-legal issues

For General Practitioners, it is accepted that abnormal test results require follow-up. The higher the risk of harm, the more urgent the follow-up must be – hence, the Coroner’s criticism of Dr Lim.

Importantly, this case serves as a prompt for radiology practices to ensure policies are in place for managing unexpected abnormal results, including after hours. Accordingly, when revising or looking to put a policy in place, the following may need consideration:

  • Where unexpected sinister results are found, it is preferable that the referring doctor is contacted before the patient leaves the practice. 
  • Where possible and relevant, a discussion between the patient and referring doctor may need to be facilitated. 
  • A written record of the discussion with the referring doctor should be made.

  • Formal reports should reflect the urgency of follow-up, and confirm contact with the referring doctor. 
  • Have a protocol which takes into account the findings and/or degree of risk to the patient – outline who should be contacted and when (especially after hours) and/or when the referring doctor cannot be contacted. If the referring doctor cannot be contacted, the reporting radiologist should coordinate appropriate care for the patient2.


Patient care and safety are paramount. This is central to any risk management program. The Coroner’s commendation of the radiology practice emphasises the importance of having policies in place which provide guidance in unexpected situations to ensure patient needs. In this case, urgent access to specialist care and treatment should have been the priority. Without clear guidelines, the risk of catastrophic outcomes for patients remains high.

If you receive a claim or complaint, contact MDA National’s Medico-legal Advisory team for advice and support on 1800 011 255.

Further information can be obtained from the RANZCR Standard of Practice for Diagnostic and Interventional Radiology version 11. Sydney.

  1. Inquest into the Death of Judith Lambert, Coroner Court of SA, 13 June 2013.
  2. Standards of Practice for Clinical Radiology, RANZCR version 11. 



Communication with Colleagues, Complaints and Adverse Events, Practice Management, General Practice, Radiology, Radiation Oncology


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