Closed Claims—Open Insights: Failure to Communicate Abnormal Imaging Result

Background

A 58‑year‑old female patient presented to the emergency department (ED) with abdominal pain, nausea, and vomiting. The initial emergency physician performed a physical exam and ordered blood work, a urinalysis, and a KUB (kidneys, ureters, and bladder) radiograph. The patient’s abdomen was noted to be mildly to moderately tender without guarding or rebound. Based on a preliminary Interpretation of the KUB as normal, the physician diagnosed acute gastritis and a urinary tract infection. The patient was prescribed antibiotics, instructed to follow up with her primary care provider within two days, and discharged home.

Approximately two hours after discharge, the radiologist completed the final KUB interpretation. Although no acute abdominal abnormality was identified, a questionable density in the lower abdomen and pelvis was noted, and an abdominal or pelvic mass could not be excluded. Further evaluation with an ultrasound or a CT scan was recommended.

By that time, the initial ED physician’s shift had ended, and a second emergency physician (our insured) assumed care. The radiologist contacted the second physician to communicate the concerning finding, and the communication was documented in the radiology report. In accordance with hospital policy, the report was also automatically faxed to the patient’s listed primary care provider. However, the second physician did not contact the patient or instruct staff to notify her of the abnormal finding.

The patient did not follow up with her primary care provider. Six months later, she presented with a palpable abdominal mass. A CT scan revealed a 16‑inch abdominal/pelvic mass, and she was subsequently referred to a gynecologic oncologist. The patient underwent a hysterectomy, oophorectomy, and tumor debulking surgery and was diagnosed with advanced ovarian cancer. She died 11 months after the initial ED visit.

Allegations

• Failure to recognize and act on abnormal imaging findings
• Premature discharge before final radiology interpretation
• Negligent communication and follow‑up systems (hospital liability)
• Failure to provide adequate discharge instructions

Case Review Insights

• Abnormal test results require immediate, documented follow‑up, even after the patient has been discharged. The second ED physician’s failure to contact the patient after receiving a radiologist’s recommendation for urgent further imaging was a critical missed opportunity.
• Weak communication systems and unreliable result‑routing processes significantly increase malpractice exposure.
• A hospital’s inadequate processes for handling abnormal test results are a common root cause of delayed diagnoses and subsequent litigation.
• A delay in diagnosis often results in malpractice claims because the delay can allow a medical condition to progress from treatable to irreversible, causing greater harm than would have occurred with timely intervention. When patients or families learn—typically in hindsight—that earlier recognition or follow‑up could have prevented permanent injury, worsened outcomes, or death, they understandably perceive the delay as a failure to meet the expected standard of care.
• Because delayed diagnoses often lead to advanced disease, more invasive treatment, increased suffering, and reduced survival, they present a strong causal link between the healthcare provider’s inaction and the patient’s harm—making them a common and compelling basis for malpractice litigation.
• Expert reviewers concluded that deficiencies in clinical care and failures in communication systems contributed to the delayed diagnosis.

Resolution

The matter was resolved through a pre-trial settlement, with both physicians and the hospital participating.

Lessons Learned

• Abnormal test results must be communicated and acted on immediately—even after patient discharge. Every abnormal result requires a documented, closed‑loop communication process.
• Reliable systems are essential for routing and verifying critical results. Healthcare organizations must maintain accurate provider contact information and implement safeguards that verify receipt of time-sensitive results.
• Shift-to-shift communication must ensure continuity of responsibility.
• Preliminary imaging reads should not replace clinical vigilance. ED teams should have protocols for reconciling final imaging results and for ensuring rapid patient contact when necessary.

Risk Management Tips

• Implement a closed-loop system for abnormal test results.
• Maintain accurate provider contact information and verify transmission of results.
• Establish clear accountability during shift changes.
• Reinforce that preliminary imaging reads do not replace final interpretations.
• Patients discharged before final radiology review remain at risk if no system ensures timely reconciliation of interpretations. Adopt policies requiring final imaging reports to be reviewed promptly with a defined workflow for patient notification when findings differ from the preliminary assessment.

Resources

• Improving Handoffs in the Emergency Department
• Practice Guideline for Communication of Diagnostic Test Findings

Disclaimer

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.