Coroner's Finding: Burg, Claus Hartmuth

70y · Male·metastatic gastric adenocarcinoma

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.