News | Computed Tomography (CT) | October 21, 2020

Patient Dies After CT Scan Mix-up

According to an inquest, a man with a heart disorder and chest pain died two days after a doctor viewed the wrong scan and sent him home

According to an inquest, a man with a heart disorder and chest pain died two days after a doctor viewed the wrong scan and sent him home

October 21, 2020 — The BBC News reported that Luke Allard of Mill Houses, King's Lynn, died at Queen Elizabeth Hospital in March one day after being discharged. Allard, 28, had Marfan syndrome, a genetic disorder that can cause heart issues. BBC reported that an inquest was heard after he was discharged when another patient's computed tomography (CT) image was looked at in error. He was recalled to the hospital once the mistake was realized the following morning, but died soon after arrival. He suffered a cardiac arrest due to a ruptured aortic aneurysm. According to the area coroner, Allard had been awaiting heart surgery at Papworth Hospital in Cambridge.

Another British publication, Eastern Daily Press, doctors from QEH said the hospital was putting measures in place to prevent similar errors, including upgrading its internal computer systems. Radiologists must now phone the doctor who requested the CT scan to discuss, rather than asking administrative staff to do so. Eastern Daily Press also stated that fatigue could have been a factor on Masud Isham, M.D., who had finished his shift two-and-a-half hours later than scheduled.

A GoFundMe account has been established in Allard's name.

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Cardiac Magnetic Resonance Imaging in Athletes With Clinical and Subclinical Myocarditis A-D, Athlete A with subclinical possible myocarditis was asymptomatic with normal electrocardiogram (ECG), echocardiogram, and high-sensitivity troponin findings. A, T2 mapping showing elevated T2 in basal-mid inferolateral wall in short axis view. B, late gadolinium enhancement (LGE) in the basal inferolateral wall in short axis view. C, Postcontrast steady state-free precession (SSFP) images showing contrast uptake in the basal-mid inferolateral wall in short axis view. D, LGE in the inferolateral wall in 3-chamber view. E-H, Athlete B with subclinical probable myocarditis was asymptomatic with normal ECG, normal echocardiogram, and elevated high-sensitivity troponin findings. E, T2 mapping showing elevated T2 in the anteroseptal wall in short axis view. F, LGE in the anteroseptal wall in 3-chamber view. G, T2 mapping showing elevated T2 in the anteroseptal wall in 3-chamber view. F, Postcontrast SSFP image showing pericardial effusion in short axis view. I-K, Athlete C with clinical myocarditis and chest pain, dyspnea, abnormal ECG, normal echocardiogram, and normal troponin findings. I, T2 mapping showing elevated T2 in the lateral wall short axis view. J, Postcontrast SSFP images showing contrast uptake in midlateral wall in short axis view. K, LGE in the epicardial midlateral wall in short axis view. L-N, Athlete D with clinical myocarditis, chest pain, abnormal ECG, echocardiogram, and troponin findings. L, T1 mapping showing elevated native T1 in midlateral wall in short axis view. M, T2 mapping showing elevated T2 in the midlateral wall in short axis view. N, LGE in the epicardial midlateral wall in short axis view. IR indicates inferior right view; IRP, inferior, right, posterior view; PLI, posterior, left, inferior view; SL, superior left view; SLA, superior, left, anterior view. Image courtesy of JAMA Cardiol. Published online May 27, 2021. doi:10.1001/jamacardio.2021.2065

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