125 results for “radiology imaging”
71y · Female·aortic dissection (Stanford Type A)
… could not adequately exclude dissection, but this critical limitation was not clearly communicated from radiology to cardiology. A consultant radiologist's amendment recommending repeat CT imaging with ECG gating was a…
34y · Male·Cardiac tamponade due to hemopericardium from acute aortic dissection of the asc…
…logical findings, failure to perform full re-triage on representation, and absence of system tracking of radiology reports. Clinical lesson: sudden-onset chest pain with persistent symptoms despite GORD treatment warran…
78y · Female·Complications of a left tentorial meningioma
…y could be performed. The coroner found neurosurgical management appropriate but identified that the 2009 imaging report recommending no follow-up represented a missed opportunity for surveillance of tumour growth. Key …
65y · Male·Metastatic adenocarcinoma of unknown primary origin
…ugust, with results reported three days later, revealing pulmonary nodes and pleural effusion. Subsequent imaging identified hepatic lesion and metastatic disease. Care after diagnosis was of high standard including pal…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
…f an 8.7 cm AAA was identified on a lumbar spine X-ray in August 2021, but confirmatory ultrasound and CT imaging were not performed until February 2022. Critical failures included: the PMO's failure to indicate urgency…
44y · Male·Metastatic small cell neuroendocrine carcinoma of lung
…tember 2010 with respiratory symptoms. A chest x-ray that day revealed a mediastinal density reported by radiology as possibly requiring CT investigation, but this was not followed up for nearly two months until diagnos…
81y · Male·Head injury sustained in a fall
…mmunication protocols for critical radiological findings, recognizing that isolated IVH requires specific imaging expertise, and implementing systems that detect human error before patient harm occurs.
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
…ment failed to image her cervical spine despite seatbelt bruising and institutional guidelines requiring radiology for trauma patients over 65 years; (3) a CT shoulder scan failed to detect the cervical fracture; (4) IC…
69y · Female·left pontine haemorrhage with re-bleeding associated with hypertensive vascular …
A 69-year-old woman died from left pontine haemorrhage with re-bleeding. On 2 February 2010, her GP referred her for a CT head scan after she reported two weeks of slurred speech. The scan on 11 February revealed a ponti…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
…entually revealed basilar artery thrombosis with extensive infarction on 10 September afternoon, the LGH radiology department failed to contact NWRH clinicians, and NWRH staff were unaware they could access results via …
43y · Female·pulmonary embolism
…Ultrasound was performed but did not extend above the inguinal ligament. She was reassured after negative imaging and the intrauterine balloons were removed. She collapsed the next morning with massive bilateral pulmona…
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…
49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…
Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…
87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…
An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural …
76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus
… presented to ED with sudden onset left-sided abdominal pain, vomiting and bowel incontinence. Initial CT imaging was reassuring. However, mesenteric ischaemia—characterised by severe pain without significant clinical s…
40y · Male·haemopericardium complicating ascending thoracic aortic dissection
…two days later from rupture of an ascending thoracic aortic dissection with haemopericardium. Post-mortem imaging revealed widened mediastinum on the initial chest x-ray. The coroner found preventable failures: the x-ra…
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 radiologis…
69y · Male·thoracic aortic aneurysm with dissection
…nicians to maintain high clinical suspicion for aortic dissection when symptoms are consistent, even when imaging reports appear to exclude it. The case highlights gaps in quality assurance systems for imaging services.
Female·haemopericardium due to aortic dissection (all three cases)
…ed: aortic dissection absent from ACS pathways, lack of senior review, incomplete clinical information on imaging requests, delayed radiologist review, and failure to consider differential diagnoses when troponin was ne…
33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…
…acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; repeat CT after 50 minutes showed significant progression with incr…
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