Coroner's Finding: Burg, Claus Hartmuth
Deceased
Claus Hartmuth Burg
Demographics
70y, male
Date of death
2019-09-28
Finding date
2026-08-06
Cause of death
metastatic gastric adenocarcinoma
AI-generated summary
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologists (perceptual errors). A July 2018 CT showed the same thickening, but radiologist Dr M. reported it ambiguously as 'possibly thickened' and did not follow notification procedures requiring direct communication to the referring clinician. The oncologist Dr P., misled by vague language, failed to conduct further assessment and discharged the patient from monitoring. The cancer progressed to incurable stage 4 disease with pancreatic invasion. Clinical lessons: radiologists must systematically examine all anatomical structures; significant findings must be reported clearly and directly communicated to referring clinicians; results-tracking systems are essential to prevent missed follow-up.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to detect stomach wall thickening on February 2017 CT scan by radiologist Dr C.
- Failure to detect stomach wall thickening on February 2018 CT scan by radiologist Dr R.
- Ambiguous reporting of stomach thickening on July 2018 scan as 'possibly thickened' by Dr M.
- Failure to include significant findings in report conclusion
- Non-compliance with SA Medical Imaging procedures requiring direct notification of significant findings to referring clinician
- Oncologist's failure to conduct clinical assessment or review source images
- Absence of results-tracking system for medical imaging
- Perceptual errors by radiologists focusing on bladder cancer recurrence rather than incidental pathology
- 'Satisfaction of search' phenomenon after identification of lung nodule
- Lack of formal protocol requiring comprehensive review of all anatomical structures within scanned volume
Coroner's recommendations
- Royal Australian and New Zealand College of Radiologists to develop template or guidance for CT, plain x-ray and MRI reporting to ensure all anatomical structures within scanned volume are critically reviewed and reported upon regardless of area of concern specified by requesting clinician
- College to consider protocol for stomach preparation by water filling prior to CT scans to increase detection of incidental gastric pathology
- College to publish bulletin raising awareness that stomach cancer can be detected incidentally on any CT including stomach and this is most likely means of detecting stomach cancer at treatable stage
- SA Medical Imaging and Minister for Health to more clearly define circumstances requiring call to requesting clinician within Notification of Significant and/or Unexpected Findings procedure
- Statewide requirement for radiology hard-copy and electronic request forms to include working-hours and after-hours contact details for requesting clinician
- Consider implementing artificial intelligence assistance in interpretation of imaging to support radiologist interpretation
- Minister for Health to introduce statewide policy requiring internal review processes to engage with clinicians involved in sensitive manner to ascertain their versions of events
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