Learning from cases: Radiology
Post date: 17/11/2023 | Time to read article: 11 minsThe information within this article was correct at the time of publishing. Last updated 21/11/2023
Read this resource to:
- understand common themes from radiology cases in the UK in which we have supported members
- receive tailored advice and key recommendations to help you reduce risks in the future.
Radiology is a unique field, so the advice you receive needs to be equally specialised.
As a Medical Protection member, you benefit from more than 130 years of experience defending doctors and other healthcare professionals. That isn’t just a number – it’s more than 13 decades of specialist expertise that we use to protect you long into the future.
The team at Medical Protection, including medicolegal experts and cases and claims specialists, have delved into a huge range of radiology cases to analyse the common reasons for claims and the different case types, to help keep you up to date with the current trends and provide insights into the radiology claims and complaints landscape. We hope you find this a useful source of guidance and advice, empowering you to protect yourself throughout your career.
Introduction
Clinical negligence claims and medicolegal cases, such as inquests, complaints, and regulatory matters, are not uncommon.
The majority of radiology claims reported to us are from private practice, whereas other case types would usually arise from both the NHS and private settings. Although clinical negligence claims do arise from the NHS setting, the management of these is usually done via NHS Resolution (but it’s important to check what it says in your contract). Medical Protection will, however, still assist in reviewing statements relating to a claim prior to submission to the Trust’s legal team.
Clinical negligence claims in radiology, especially in relation to reporting errors leading to a missed diagnosis, and hence delay, can sometimes lead to large financial settlements. The value of the settled claim will often include compensation for care and loss of earnings, in addition to an award for the damages resulting from a breach of duty.
Delay in diagnosis can result in permanent damage or significant loss of function, and so the value of claims can vary enormously. Our highest radiology total case payment relating to an error in reporting between 2016 and mid-2023 (including claimant damages, claimant solicitor costs, and other legal costs) was in excess of £400,000.
COVID-19 meant there was a significant change to the way in which many doctors worked, including disruption to clinics, procedures, and a move to remote consultations. In radiology, The Royal College of Radiologists issued guidance regarding changes that could be made for a period of time to support a number of NHS clinicians to work from home when they might not otherwise have been able to do so.
In addition, we saw a large number of individuals contacting our medicolegal helpline for advice and support throughout the pandemic.
Issues more generally arising as a consequence of COVID-19, included the prioritising of scarce resources, concerns over staffing levels, and provision of PPE, COVID-19 vaccinations (including issues over doctors who did not wish to be vaccinated and also those who had fraudulently obtained vaccinations for themselves or their family ahead of schedule), management of patients who refused to wear a mask, and worries about personal risk of exposure. Medicolegal cases where COVID-19 is cited as a factor are ongoing, and it is likely the impact will continue to be felt for some time.
We understand you work in complex and often pressured environments. We also know, following feedback from members, that experiencing a medicolegal case can be incredibly stressful. At Medical Protection we want to share our knowledge, experience, and expertise with you, so we can provide invaluable professional support.
Analysis
We’ve analysed the support we provided UK-based radiologists in almost 800 cases between 2016 and mid-2023. In addition to providing advice and assistance in writing medical reports in nearly 200 of these cases, we have supported our members through over 600 other scenarios, including:
- claims – demands for monetary compensation that embodies allegations of negligence
- potential claims – intimations from a claimant of a possible claim for compensation
- complaints
- General Medical Council (GMC) investigations
- local disciplinary procedures
- inquests
- medicolegal advice.
We have studied all clinical negligence claims in radiology, including those defended, not pursued, and settled. We feel sharing what we have learned about why patients decide to take action – and the reasons why radiology claims are settled – is valuable.
In our analysis of radiology cases, such as regulatory and complaint matters, we have identified common themes that may lead to a concern being raised about a clinician.
Claims
Almost 200 clinical negligence claims arising from private radiology practice reported between 2016 and mid-2023 were reviewed.
Common themes included:
- complications arising from interventional radiology procedures
- failure to obtain informed consent
- failure to request additional views, eg, for consideration of slipped upper femoral epiphysis
- allegations of errors or discrepancies in reporting, including:
- misdiagnosis of an abnormality – for example, reporting a benign lesion as likely malignant, and vice versa
- missed abnormalities, including:
- primary tumours
- metastases
- fractures
- anastomotic leak
- stroke
- subarachnoid haemorrhage
- subdural haematoma
- cauda equina
- multiple myeloma
- epidural abscess
- bowel perforation.
Common themes
Complaints
We have analysed over 100 complaints about radiologists, including complaints arising from both the NHS and private practice. These were quite varied and sometimes related to multiple concerns. Most of the complaints were from patients, but some were from other healthcare professionals.
The common themes were:
- missed or delayed diagnosis as a result of an error in interpreting images
- inappropriate physical contact or examination
- poor manner and attitude, including lack of empathy
- inadequate consent for procedures
- complications post-biopsy, eg bleeding
- incorrect biopsy sample obtained, eg from the kidney rather than the liver
- nerve damage following insertion of lines.
Inquests
We assisted members in writing statements and attending coroners’ inquests on approximately 90 occasions. An inquest is a fact-finding exercise that is conducted by the coroner and, in some cases, in front of a jury.
The purpose of an inquest is to find out who died, when, where, and how (sometimes referred to as “in what circumstances”). Our inquest factsheet contains further information about what happens at an inquest.
We identified the following issues leading to members being asked to provide a statement or give evidence at an inquest:
- Missed or delayed diagnosis as a result of errors in reporting, including missed subarachnoid and subdural haemorrhage – in some cases where haemorrhage was not identified, anticoagulation was then given and further bleeding resulted.
- Death, including from haemorrhage or air embolus, during or following interventional radiology procedures such as biopsies.
- Missed leaking abdominal aortic aneurysm.
- Missed pulmonary embolus.
Criminal
A small number of criminal cases were identified, and the majority of these related to allegations of inappropriate examination of patients.
Advice
We received over 130 requests for written advice on a wide range of medicolegal issues, with common themes including:
- raising concerns – including about colleagues, staffing, and resources
- being a witness for an investigation into the practice or behaviour of a colleague
- what to do if requested to discuss private patients in NHS multi-disciplinary teams (MDTs)
- how to approach situations where other clinical colleagues do not follow recommendations included in the radiology report
- queries about duty of candour – professional and statutory.
Regulatory (GMC) and disciplinary cases
We are aware of the immense pressure and stress that many doctors go through during these investigations. We always aim to provide members with tailored care and expert support. GMC cases and hospital disciplinary matters have followed concerns raised by patients, relatives, or colleagues, both senior and junior. There was a mix of clinical and non-clinical concerns. Some investigations related to more than one concern or a series of serious clinical incidents.
The common themes were:
- concerns in relation to clinical competence, including reporting of images and interventional procedures
- inadequate supervision of trainees
- inappropriate examination of patients
- concerns about competence to perform interventional radiology procedures
- allegations of domestic violence
- failure to obtain car tax or insurance
- writing prescriptions for self or family
- inappropriate touching or sexual assault allegations, both inside and outside the work environment
- drink driving
- conducting work in the private sector when off sick from NHS work or while scheduled to be working in the NHS
- claiming waiting list initiative payments when not entitled to do so
- accessing medical records inappropriately
- failing to declare previous investigations or dismissal on application forms or during interviews.
In the absence of representation by a defence organisation, the cost of instructing a solicitor to assist with a regulatory or disciplinary matter can be significant. For example, the costs incurred on one of the cases considered during this time period was in excess of £65,000.
Reports
Assistance was provided in almost 200 report case types. For example, for a Trust’s ‘serious untoward incident’ investigation or for providing a statement to assist the Trust in a clinical negligence claim. In a number of these cases, a statement was also requested for the coroner for the purposes of an inquest.
The common themes were:
- errors in reporting, including missed diagnosis – for example, missed tumours, subarachnoid haemorrhage, and fractures
- performing a biopsy on the incorrect side
- complications of an intervention procedure such as a biopsy, including where injury to other structures occurred
- declining to perform imaging
- inappropriate examination and alleged sexual assault of patients
- delays in diagnosis, eg of cauda equina
- requests for court reports in relation to suspected non-accidental injury.
Remote radiology reporting
During our analysis we identified an increasing number of claims and cases associated with outsourced remote radiology reporting.
As a specialty, radiology is not new to remote working, but external remote radiology reporting has been increasing in hospitals over the past few years, with outsourcing often resulting in the ability for reports to be completed 24/7 and allowing for a greater volume of imaging to be undertaken.
With recognised shortages in the consultant workforce for radiology, and the increasing use of radiology for diagnostic purposes, it is unsurprising that outsourcing of work is required. While pragmatically speaking it should allow for a greater volume of reporting, the associated risks have not gone unnoticed. In 2020, a patient safety report published by “Getting It Right First Time”1 highlighted a number of areas where outsourced remote reporting might contribute to systemic problems.
The risks of radiology reporting have also been highlighted in a report undertaken by the Parliamentary and Health Service Ombudsman in 2021.2 While this report looks at reported failings in the NHS, remote reporting may be undertaken for NHS trusts, but requiring individual indemnity for radiologists. It is important that those undertaking remote reporting ensure they are aware of the indemnity requirements. Check your contract for the details of what indemnity arrangements are required to cover you, and ensure you keep a copy as claims can arise many years down the line.
Two key problematic areas that have been identified by the reports above and are also seen in cases managed by Medical Protection include:
IT systems
Many systems do not allow image sharing between hospital trusts. This can result in previous imaging being unavailable and leaves the reporting radiologist exposed to potential risk. It can also result in further, unnecessary, imaging being suggested.
Communication
Radiology request forms are only as good as the level of detail included on the form. If important clinical detail is not included and face-to-face communication cannot occur, then the reporting radiologist may be clinically disadvantaged. Remote reporting can also result in the loss of communication with other healthcare professionals, either through the lack of a traditional MDT or loss of easy ability to contact the referring clinician. This can result in lost opportunity to seek further clinical correlation or secondary reviews of reports.
Similarly, receiving clinicians are unable in most cases to contact the reporting radiologist or do not have the same working relationship as those co-located in the hospital environment. This can result in reports being interpreted incorrectly, especially when the report contains ambiguity, lacks suggested further management (where relevant), or an unexpected finding is not reported in a way that highlights potential serious pathology.
How can remote radiologists reduce their risk?
While many of the problems cannot be solved by individual clinicians, it is important that those involved in remote radiology reporting still adhere to those standards expected by the Royal College of Radiologists reporting standards.3 It is also recognised that while there is an accepted reporting error rate for radiologists between 3 – 5% for plain film radiographs and higher for cross sectional imaging,4this has been shown to increase with offsite reporting. A study from 2017 showed that offsite reporting is associated with an increased rate of reporting errors – between 8.7% and 12.7% – which highlights the importance of ensuring that when offsite reporting there is a robust system to allow for learning from errors.5
Some of the key areas that can assist teleradiologists in reducing risk include the following:
- Ensuring the report wording is unambiguous – this is especially important for those reporting for a company and not directly alongside the referring clinician when it may not be possible to tailor a report to the professional background of the requesting clinician. Plain English should be used, avoiding acronyms, abbreviations, and colloquialisms. An explanation should be provided for any medical terminology that is unusual or may be subject to interpretation.
- When reporting images, pertinent previous radiology should be considered, or if not available, this should also be stated, along with clinical information and laboratory/histopathology reports. This can be a barrier for those reporting remotely for a third party without access to patient records. The report should therefore consider whether knowledge of results would change the report and consider whether the information needs to be obtained.
- When unexpected significant clinical findings or life-threatening emergencies are identified, the reporting radiologist should comply with local escalation or referral mechanisms. This is a key area that can result in negligence claims or potential criticism of practice, and Medical Protection has seen claims – for example, delayed diagnosis of cauda equina – relating to poor reporting pathways. Radiologists should ensure, if they are providing their service to a company, that they are satisfied there are robust reporting mechanisms and be aware of the referral pathway before undertaking the work. If a clinician cannot satisfy themselves that the pathway is adequate, the risk of a claim increases, and it is likely that there will be some responsibility attributable to the radiologist as well as the organisation.
- Those reporting for external organisations or taking on additional reporting workload should consider the increased risk of errors associated with working above contracted hours, as well as the increased risk associated with reporting during nighttime hours.6
Clinicians should ensure they are satisfied that the remote radiology companies to which they are contracted facilitate a service that is subject to quality assurance. This should include access to, and participation in, radiology events and learning meetings (REALMs) and relevant CPD.
Quality assurance should also include discrepancy reporting in line with Royal College of Radiologists standards. This ensures that colleagues undertaking remote reporting are subject to the same scrutiny and can learn from the peer reviews undertaken of their work.
Radiology in the UK: Top tips to minimise risk
Please note this is not an exhaustive list of recommendations, but key learning points from our analysis:
- Ensure your clinical management is regularly updated and in line with current best practice, such that it would be supported by your peers.
- Ensure accurate and clear documentation, and that the wording of your reports is unambiguous. Where applicable, ensure you have included recommendations for the referring clinician to consider (such as the need for further imaging), and where appropriate, you have set out any areas of uncertainty in the interpretation of imaging. Such documentation may need to be relied on years after the event and is the cornerstone of any medicolegal defence.
- Ensure relevant previous radiology is reviewed and considered.
- Comply with local escalation or referral policies, especially when unexpected significant abnormalities are detected.
- Ensure you follow the standards and guidance set down by the Royal College of Radiologists.
- Where applicable, discuss the possible benefits and risks of all potential treatment options, including no treatment. Consider what is most important to each patient, taking into account their current employment and personal interests. Listen to your patients and understand and explore their concerns and expectations. Ensure you explain frequent and serious complications (even if the serious complications are rare) and the implications for the patient if these occur. Explain what you would do to address any complications. Document these discussions.
- Ensure you treat colleagues with respect and maintain good communication with other specialties that may be involved in the care of your patients.
- If consulting with patients remotely, ensure you have all the necessary information on which to base your clinical management decisions, and that arrangements are in place for a face-to-face review should that be necessary.
- When the procedure or consultation is on a private basis, your patients should be given clear information about ALL the costs involved, and what their rights are to a refund or return of deposit if they change their mind after having paid some or all of the costs.
- When things go wrong, most patients just want two things: an explanation and an apology.
- Be open and honest with patients and their families. Be welcoming, listen to feedback, and address concerns promptly and in the spirit of co-operation.
- Ensure you are fully indemnified to carry out all the work you conduct in the UK. If you are considering reporting on images from patients based in other countries, or you are reporting on UK patients while based abroad, you should contact Medical Protection to discuss this further.
1 Getting It Right First Time. Radiology: GIRFT Programme National Speciality Report. NHS, 2020
2 Parliamentary and Health Service Ombudsman. Unlocking solutions in imaging: Working together to learn from failings in the NHS. 2021
3 Standards for the reporting and interpretation of imaging investigations. Second. London: Royal College of Radiologists 2018
4 Maskell G. Error in radiology—where are we now? The British Journal of Radiology 2019;92:20180845. doi:10.1259/bjr.20180845
5 Howlett DC, Drinkwater K, Frost C, et al. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: Results of a UK national audit. Clinical Radiology 2017;72:41–51. doi:10.1016/j.crad.2016.10.008
6 Patel AG, Pizzitola VJ, Johnson CD, et al. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Radiology 2020;297:374–9. doi:10.1148/radiol.2020201558
About the authors
The authors of this guidance have worked with Medical Protection as medicolegal consultants since 2016, assisting members in relation to many of the matters outlined above. Our experts help doctors through a range of medicolegal issues and challenges, and regularly write articles and give talks on associated topics.
Dr Heidi Mounsey
Heidi initially trained in anaesthesia and then palliative medicine before joining Medical Protection, where she has worked in both the claims and cases teams.
Dr Emma Green
Emma worked as an emergency medicine doctor until joining Medical Protection. She also returned to the frontline to assist during the COVID-19 pandemic. During her time at Medical Protection, Emma has worked across a range of departments, including claims, case handling, and more recently in underwriting.
Dr Sophie Haroon
Sophie is a medicolegal consultant in the claims team. She trained in paediatrics before becoming a Consultant in Public Health Medicine for several years and then joining Medical Protection.
