The fallibility of fax machines to communicate test results – Inquest into the death of Mettaloka Malinda Halwala24 September 2018 | Health Sector
Mettaloka Malinda Halwala was 58 years old when he died from complications of the chemotherapy he was receiving for Hodgkin’s lymphoma. Prompt and effective communication of his abnormal test results may have prevented his death from this cause.
At the time of his death, Mr Halwala was living alone in a hotel near Shepparton in Victoria, having moved there to work as a civil engineer.
On 11 November 2015, a Positron Emission Tomography (PET) scan suggested that Mr Halwala may be suffering from toxicity to his chemotherapy. Despite this, two days later, Mr Halwala received another dose of chemotherapy. This occurred because the haemotologist who had ordered the scan was unaware of the results.
On 16 November 2015, Mr Halwala called his haemotologist to report feeling unwell and was told to go to hospital. He never made it. The next morning, Mr Halwala was found deceased fully clothed in his bed in his hotel room.
Victorian Coroner Rosmary Carlin held an inquest to determine the adequacy of Mr Halwala’s medical management in the lead up to his death, particularly in relation to why the haemotologist did not know the results of the PET scan until after Mr Halwala had received another dose of chemotherapy. The Coroner focused on the respective roles and responsibilities of diagnostician and referring doctor in relation to the communication of unexpected test results.
The Coroner found that there were shortfalls in the medical management of Mr Halwala on the part of both the nuclear medicine physician who performed the PET scan and the referring haematologist. The Coroner could not be certain that Mr Halwala would have survived even with optimal treatment, but found that he may have. The shortfalls in his medical management deprived him not only of this chance of survival, but also of the opportunity to have a more comfortable death surrounded by loved ones.
The role of the diagnostician
The Coroner commented that nuclear medicine physicians and radiologists are not just diagnosticians, they are first and foremost medical practitioners. Although they have never met the people who are the subjects of their reports, those people are still their patients to whom they owe a duty of care and for whom they have a continuing responsibility until they return care to the referring doctor by communicating the results in a manner that is both effective and appropriate to the circumstances.
The Coroner referred to the Australian Association of Nuclear Medicine Specialists Standards for Accreditation of Nuclear Medicine Practices (AANMS Standards) which, under the heading “Timeliness of Reports”, states:
“The timeliness of reporting will vary with the nature and urgency of the clinical problem. In general, the report should be sent to the referring practitioner within 24 hours of completion of the study. If there are urgent or unexpected findings, the specialist should use reasonable endeavours to communicate directly to the referrer or an appropriate representative who will be providing clinical follow up.”
When are results unexpected?
The Coroner found that when communicating potentially abnormal test results, what must be considered by a diagnostician is the expectation of the referring doctor. A diagnostician may have a high threshold for whether something is unexpected by virtue of their exposure to a much greater range of results. However, as stated by the Coroner, diagnosticians are not formulating reports for their own gratification and information, they are intending to communicate something to the referring doctor and ultimately the patient.
In this case, the Coroner found that the nuclear medicine physician ought to have appreciated that Mr Halwala’s test results would not have been expected by the haematologist and used reasonable endeavours to directly communicate those results to the haematologist.
How should unexpected results be communicated?
As to what constitutes direct communication in the context of urgent or unexpected findings, the Coroner found that the AANMS Standards were clearly intending to convey something over and above the usual method of communication. What was required was communication that provided immediate confirmation that the report had been received, understood and acted upon – in other words actual dialogue.
Absent any other means of achieving this, the Coroner found that the nuclear medicine physician ought to have picked up the phone and spoken to the haematologist either that night or the next morning. Instead, she relied on two assumptions. First, that the fax would be received and read by the haematologist within 24 hours. Second, that the haematologist would review the results before any further treatment. The Coroner stated that the potential for something to go wrong here should have been obvious.
As it turns out, the fax was sent to the wrong number. Notwithstanding this, and even if the fax was sent to the correct number, the evidence was that the haematologist shared a fax machine within 20 other doctors. It was located on the ground floor of the building when his office was on the sixth floor. The faxes were generally placed in a tray, but sometimes documents were picked up by the wrong person. This is often the situation in large hospitals and other organisations.
The Coroner commented that the nuclear medicine physician’s reliance on the haematologist to seek out the report before any further treatment was dangerous, even if it was reasonable to expect that he would do so. While it is true that the haematologist was Mr Halwala’s primary treating physician, in relying on him to chase the report, the nuclear medicine physician put aside her own duty of care and responsibility for Mr Halwala’s welfare.
The role of the referring doctor
The Coroner found that the haematologist should have ensured that he read the PET report before Mr Halwala’s next chemotherapy session. Having ordered the PET scan, whether he had anticipated abnormal results or not, it was incumbent on the haematologist to make sure he read the results promptly. It was information that was available to him and he had a duty to make use of it.
Further, the Coroner stated that the haematologist’s assumption that the nuclear medicine physician would inform him of any significant abnormal results suffers from the same flaws as the assumptions made about his conduct. The Coroner said that having this belief did not absolve the haematologist of his own responsibility to make certain that there was nothing untoward in the results, even it was reasonable to expect that abnormal results would be communicated to him in a different way to expected and routine results.
Additionally, when the haematologist did receive the unexpected PET results by post on the afternoon of 16 November 2015, he should have made efforts to ensure that Mr Halwala went to hospital. The haematologist gave evidence that he had never seen such an abnormal result on a PET scan, and knew that the result potentially represented a severe reaction to the chemotherapy. He knew that Mr Halwala had received another dose of chemotherapy since the scan, that Mr Halwala had called that day complaining of feeling ill, and that he lived alone in a hotel room. The haematologist had still not contacted Mr Halwala by mid morning on the following day, which the Coroner said seems remarkably indifferent.
Conclusion & Recommendations
The Coroner commented that this case illustrates the difficulties that may be encountered in patient management where different components of care are delivered by individuals and institutions geographically separated from each other and between whom there is no established professional relationship.
Notwithstanding this, the Coroner highlighted the importance of a collaborative approach by doctors to achieve good medical care.
Both the diagnostician and referring doctor in this case considered their actions entirely reasonable and relied to a large extent on their expectation as to what the other doctor would do – expectations that proved wrong in each case.
The Coroner’s recommendations were directed to phasing out the use of fax machines, with the electronic distribution of results (including confirmation of receipt) becoming routine. The Coroner noted that electronic distribution will never be a substitute for direct, generally oral, communication of medical results in appropriate cases. However, it is obviously a vastly superior method of communication to fax, and should be used routinely and in addition to any more direct method.
To this end, the Coroner formally recommended that a set of standards dedicated to systems for the communication of test results be developed by the Royal Australian and New Zealand College of Radiologists, the Australian Association of Nuclear Medicine Specialists and Royal Australasian College of Physicians. The Coroner directed that the standards should be as explicit as possible in setting out the roles and responsibilities of the diagnostician and referring doctor and the required manner of communication in different situations consistent with the conclusions and comments in this case.
In the meantime, the Coroner recommended that the hospital in this case phase out fax transmission of imaging results as a matter of priority.