Radiology practice's communication failure bears tragic consequences

A failure to appropriately communicate ultrasound findings ended tragically for a woman in New Zealand, and a radiology group and midwife have since come under fire by health officials. 

According to reports, the woman was referred by her midwife to Pacific Radiology, which operates 47 radiology clinics throughout New Zealand, at around 41 weeks pregnant to get a fetal ultrasound exam. The scan showed low amniotic fluid and decrease in fetal weight compared to prior imaging. However, the patient was assured during her exam that her findings were “quite normal.” 

Pacific Radiology informed the woman that her results would be sent to her midwife, and she was allowed to leave. Not long after that scan, she began to experience bleeding and felt fewer fetal movements, which prompted her to call her midwife. It was then revealed that the midwife had never received the ultrasound results. 

The patient was sent immediately to the hospital, where her labor was induced. Tragically, the woman had a stillbirth. 

After looking into the case, officials discovered that a coding error had prevented the ultrasound report from ever being sent to the midwife. What’s more, the practice lacked the appropriate systems to validate the results had, in fact, been delivered to the appropriate parties.  

However, given the significance of the findings, Pacific Radiology should have promptly and directly communicated the results to the patient’s midwife, Deputy Health Commissioner Rose Wall charged in a report on the incident. 

“I am highly critical that Pacific Radiology was aware that it was using an IT system that held ‘empty’ codes, which, if selected, would result in the report in question going ‘nowhere,” Wall wrote in her report. “I am also critical that it appears that no checking systems or policies were in place for such cases…whether that be within the system itself, and/or follow-up by frontline staff.” 

Wall was also critical of the midwife for not reaching out to the radiology group when she did not receive any communication from them regarding the woman’s findings. She expressed her disapproval of the radiologist who interpreted the exam as well, stating that he also had a duty to communicate the findings. 

“I am critical that he did not take further steps to fulfil his duty as a radiologist, subject to the Communication of Critical/Actionable Results Policy, for ensuring that the results of the report were communicated successfully,” she said. 

Both Pacific Radiology and the midwife were found to have breached the Code for failing to provide services of an appropriate standard. Each were required to address and update their protocols related to communication between parties.