The Victorian coroner has criticised the medical profession's reliance on "antiquated and unreliable” faxes and called for national communication standards after a cancer patient’s test results were sent to the wrong number and he died alone in a hotel room.
The 58-year-old Hodgkin's lymphoma patient, Mettaloka Halwala, was found in his bed and fully clothed by hotel staff when they opened the door of his room on the morning of November 17, 2015. The father of two had died from chemotherapy complications.
Four days earlier a PET scan at Melbourne’s Austin Hospital had showed signs of potentially fatal lung toxicity linked to Halwala's treatment but the results were faxed to the wrong number.
“It is difficult to understand why such an antiquated and unreliable means of communication persists at all in the medical profession,” Coroner Rosemary Carlin said in her inquest findings.
Neither Halwala nor his haematologist, Dr Robin Filshie, who had ordered the scan, were made aware of the results. This, combined with other "shortfalls in his medical management", meant a further fatal dose of the same drug was administered at Goulburn Valley Hospital.
The day before he was found dead, Halwala had told Dr Filshie he felt unwell. He was advised to go to hospital but didn't make it there.
The coroner said Halwala had been "let down by the medical profession”.
"I cannot be certain that Mr Halwala would have survived even with optimal treatment but he may have," Carlin said.
"The shortfalls in his medical management deprived him not only of his chance of survival but also of the opportunity to have a more comfortable death surrounded by loved ones."
The coroner found that while "no one acknowledged responsibility for the communication failure," there had been “inadequate medical management” by Dr Filshie and the physician responsible for sending the report, nuclear medicine physician Associate Professor Sze Ting Lee.
She found that nuclear medicine physicians and radiologists are not just diagnosticians, they are first and foremost medical practitioners and have a duty of care to get results to referring doctors.
“Although they may never meet 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 said Associate Professor Lee relied on two assumptions: “First, that facsimile transmission would ensure the report was received and read by Dr Filshie within 24 hours and secondly, that Dr Filshie would pursue the results before any further treatment. The potential for something to go awry should have been obvious.”
According to the findings, the results were sent to a different fax number to that listed on the referral form.
The coroner also found that Dr Filshie was “highly unlikely” to have received the results even if they had been sent to the correct fax number, in part due to the machine’s location in the out-patient’s department on the ground floor of St Vincent’s Hospital, while his office was on the 6th floor. The fax machine also served as a printer, and was shared with 20 specialities and parts of the laboratory and microbiology department.
She called for the faxing of imaging results to be phased out at Melbourne's Austin Hospital as a matter of priority and the development of national standards for the communication of results.
"These standards should be as explicit as possible in setting out the roles and responsibilities of diagnostician and referring doctor," Carlin said.
The coroner said Austin Hospital distributed results via fax to external referrers unless they had registered with HealthLink to receive them electronically.
“Electronic distribution will never be a substitute for direct, generally oral, communication of medical results in appropriate cases. However, it is a vastly superior method of communication to facsimile transmission and, in my view, should be used routinely and in addition to any other more direct method.”
In the months leading up to his death, Halwala was living in a hotel near Shepparton for his work as a civil engineer while his family lived in New Zealand.
A lawyer representing his wife of 27 years Chula Halwala and their two daughters said in a statement the family agreed with the coroner that all clinicians owe a duty of care to patients, including when they are not providing face-to-face care.
"In their view, their beloved husband and father should never have died in the way he did, alone and without medical treatment.”