A radiologist at Calvary Public Hospital failed to spot a serious, rare, but treatable, condition. Photo: Claire Fenwicke.
A misread CT scan contributed to the death of a retired Canberra teacher who died in Calvary Public Hospital in 2021 after collapsing at home and being admitted with chest pain, Coroner Ken Archer has found.
Mr Archer found that 69-year-old teacher Peter Hanisch died of aortic dissection, a relatively rare, but often fatal, condition which occurs as a result of a tear in the inner wall of the aorta – the major artery that runs from the heart to the rest of the body.
Early diagnosis and treatment were important to maximise the patient’s chance of survival.
However, a radiologist did not identify the condition on a CT scan, and clinicians pursued other causes of his symptoms, including a possible reaction to a recent COVID-19 vaccination.
Mr Archer found that if there had been timely treatment of the aortic dissection, there would have been very reasonable prospects of saving Mr Hanisch’s life.
“Had the dissection been identified at the time of his admission to Calvary, then statistically, Peter stood a good chance of surviving for a period after any remedial surgery was undertaken,” Mr Archer found.
“Given he survived for a period of time after the initial dissection, it is more likely that the initial dissection was more limited in size.”
Mr Archer described Mr Hanisch as a loving and supportive husband to Julia Evans and a proud father to his three children.
As a passionate and dedicated teacher with a 36-year career in science and mathematics, he was highly regarded by his colleagues and students for his passion for education and his ability to inspire others.
After retiring from full-time teaching in 2017, Mr Hanisch remained committed to fostering a love for science and mathematics through relief teaching and private tutoring.
Because he died during the COVID pandemic, restrictions in place at Calvary meant that during his admission, visitors were not permitted, and his family did not see him after he was taken to the hospital by ambulance.
A solicitor’s response on behalf of the radiologist in 2022 conceded that the scans had been misread and that “the imaging does show a mural thrombus causing a thickened aortic wall, which he would usually report as a likely dissection”.
An apology was made on his behalf, saying that this was the only instance to the radiologist’s knowledge where he had “failed to report a significant finding apparent on the films, having reported many thousands of images over 26 years of doing such work”.
However, the radiologist said the hospital clinician did not ask him to review the CT images to re-check Mr Hanisch’s aorta, nor did any hospital staff do so at any time after he provided his initial report.
An internal hospital review found the changes on the CT scan were quite subtle and only detectable by a radiologist. “There was nothing that would have prompted the clinicians in the Emergency Department to question the initial findings,” it said.
Mr Archer was unable to find why the error in reading the CT scan occurred, and there was no evidence of a lack of clinical competence.
Hospital steps to make sure such an error did not happen again, by ensuring radiologist reports could be checked by another radiologist, were interrupted by the government takeover in 2023 and Canberra Health Services advised the Coroner last month that a project to enable second review of images and peer review was due to be completed by the end of March.
Eventually, the radiology services of Canberra and North Canberra hospitals will be merged.
But CHS said there was no formal policy/procedure in place for a second review of images and most second reviews occur at the reporting clinician’s request.
Mr Archer recommended that Canberra Health Services develop and publish guidance on peer review systems and procedures for imaging services provided within CHS and by private providers on behalf of CHS.
That guidance should apply to all imaging produced within the CHS, including out-of-hours imaging and imaging undertaken by private providers at Canberra Hospital and North Canberra Hospital, he said.
