Finding into death of Mettaloka Malinda Halwala

Contributing factors

• Failure of nuclear medicine physician to communicate abnormal PET scan result by direct means (telephone)
• Failure of haematologist to actively retrieve PET scan results before administering further chemotherapy
• Reliance on facsimile transmission to wrong fax number
• Assumption by nuclear medicine physician that referring doctor would chase results
• Assumption by haematologist that he would be notified of abnormal findings
• Lack of established professional relationship between doctors at different institutions
• Absence of comprehensive systems for communication of diagnostic results
• Absence of electronic distribution of results to external referrers
• Failure to follow up on patient's call reporting illness on 16 November 2015

Coroner's recommendations

1. Royal Australian and New Zealand College of Radiologists, Australian Association of Nuclear Medicine Specialists and Royal Australasian College of Physicians should collaborate to develop explicit Standards for communication of imaging results setting out roles, responsibilities and manner of communication in different situations
2. Austin Hospital should revise its ONCOLOGY REFERRAL FORM FOR PET SCAN to include all information relevant to the nuclear medicine physician in determining timeliness and manner of result communication
3. Austin Hospital should phase out facsimile transmission of imaging results as a matter of priority