Learning from cases: Radiology

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.

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

Regulatory (GMC) and disciplinary cases

• 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.

• 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

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

Radiology in the UK: Top tips to minimise risk