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Mistaken Biopsy Report Results in Patient’s Death, Million Dollar Settlement

Doctors are responsible for personally reviewing the results from any tests they order for a patient, and ensuring that the results and next steps are pursued in a timely manner.

Because her doctor failed to review the results of a diagnostic test, the 51 year old woman in this case died from endometrial cancer after a biopsy report indicating insufficient tissue for diagnosis was mistakenly relayed to her as “normal.”

Her death could have been prevented had treatment begun early enough. Because of the missed test results, the woman waited for more than a year before she was diagnosed and treated.

This woman went to her primary care physician and nurse practicioner several times for vaginal bleeding and pain during intercourse. She was treated for vaginitis, and she was referred to her gynecologist for further evaluation.

She went to her primary gynecologist three times over a six-week period with complaints of vaginal spotting. A pap smear was normal. A pelvic ultrasound showed widening of the endometrial stripe. Due to the abnormal bleeding and abnormal ultrasound findings, the gynecologist recommended an endometrial biopsy.

The patient deliberated a few days before deciding to have the biopsy. A covering gynecologist did the procedure because the primary gynecologist went on vacation and the patient wanted it done before she herself left for a trip. After the biopsy was completed, the gynecologist advised the patient to follow-up with her primary gynecologist when she returned.

The pathology report noted blood, mucous and scant endocervical epithelium or tissue, with immature squamous metaplasia or benign changes and glycogenated squamous epithelium (normal cervical findings). However, the report also indicated there was no endometrium present, indicating the tissue was insufficient for diagnosis. The purpose of the test was endometrial biopsy.

Upon receiving the results, the gynecologist who performed the biopsy forwarded them to the woman’s primary gynecologist without personally reviewing the contents. When the woman called urgently for her results before her trip, a nurse practitioner at the health center located the report; upon seeing “normal cervical findings,” she interpreted it to mean the biopsy results were normal.

The nurse practitioner advised the woman of the “normal” result and documented it in the patient’s chart. She also included the result and the patient communication in an e-mail summary for the primary gynecologist when he returned.

Upon his return, the gynecologist saw the message from the nurse practitioner and did not personally review the pathology report itself, assuming the covering gynecologist who did the biopsy reviewed the formal report. As a result, the biopsy was not repeated, and both the provider and the woman pursued the symptoms no further than the differential diagnosis of uterine lesions.

A year later, the woman was at a well visit with her primary gynecologist, and she mentioned continued vaginal spotting, which she “got used to.”

Another pelvic ultrasound showed an endometrial stripe of 23 mm with bilateral ovarian masses. A repeat endometrial biopsy showed stage III adenocarcinoma of the uterus with metastatic ovarian cancer.

The woman had a hysterectomy, bilateral oophorectomy, omentectomy followed by chemotherapy and radiation therapy. She eventually developed pulmonary metastases and died from the disease.

The woman’s family sued the two gynecologists, her personal care physician and the nurse practitioner, alleging negligence for a two-year delay in diagnosing her endometrial cancer, leading to her premature death. The case was settled for more than $1 million.

This case had all the elements for a successful medical malpractice settlement.

The doctor did not read results from a diagnostic test. A physician performing a diagnostic test is responsible for receiving and checking the results, as well as either following-up directly with the patient or with the referring provider. A referring physician who continues to follow a patient for the problem that gave rise to the referral, has a responsibility to read the full pathology report, not just a note in the chart by someone else. It was the primary gynecologist’s responsibility to read the pathology results and schedule a repeat biopsy.

Lack of communication between providers. This can lead to confusion and misunderstandings as to who is responsible for coordinating the patient’s care, which can lead to important findings falling through the cracks, and ultimately to missed or delayed diagnoses.

Misinterpretation of test results. Office practices need clear guidelines around the communication of test results to patients.

The biopsy was not repeated. An assumption of a benign cause of the woman’s abnormal vaginal bleeding and enlarged endometrial stripe was carried forward for more than a year without further evaluation. Abnormal findings and continuing symptoms should be explored until a definitive diagnosis is made. Non-resolving symptoms are a cue for providers to reassess indicators and laboratory findings or to pursue additional tests and consultations.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.




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