Finding into death of Mettaloka Malinda Halwala
Deceased
Mettaloka Malinda Halwala
Demographics
58y, male
Date of death
2015-11-16
Finding date
2018-05-10
Cause of death
Complications of chemotherapy for the treatment of Hodgkin lymphoma
AI-generated summary
Mettaloka Halwala, 58, died from complications of bleomycin toxicity during Hodgkin lymphoma chemotherapy. A PET scan on 11 November 2015 showed widespread lung uptake suggestive of bleomycin pneumonitis, but the haematologist did not receive the results before administering another chemotherapy dose on 13 November. The nuclear medicine physician relied on facsimile transmission and assumed the referring doctor would chase results; the haematologist assumed he would be notified of abnormal findings. Neither occurred. Critical clinical lessons: (1) diagnosticians must use direct communication (telephone/email) for unexpected or significant findings, not facsimile; (2) referring doctors must actively retrieve test results before treatment decisions, not rely on notification; (3) systems must include fail-safes such as electronic distribution to patient, GP, and treating institution; (4) shared understanding between geographically separated clinicians cannot be assumed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
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
- 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
- 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
- Austin Hospital should phase out facsimile transmission of imaging results as a matter of priority
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