Radiologist numbers and after-hours arrangements at the Launceston General Hospital have not changed since the death of a 17-year-old Newnham man in May 2021.
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In his findings into the death of Kane Mathew Leary, coroner Robert Webster found that the failure by an offsite radiologist to spot a dissection of the carotid artery meant that Mr Leary did not receive a lifesaving procedure.
Mr Webster recommended that the Tasmanian Health Service consider and explore whether employing more radiologists could improve the delivery of medical services during regular hours and in-house radiologists after hours.
"It seems to me that this case demonstrates the delivery of medical services could be improved if more radiologists were employed," he said.
When asked by The Examiner whether any radiologist had been hired, a spokesman for the Department of Health said," The Department regularly reviews the demand for clinical services at our hospitals and considers necessary adjustments in line with trends and available resources, including on-site versus on-call components."
"We acknowledge release of the Coroner's findings and will review the report's recommendations as part our established safety and quality review processes."
The spokesman said i-Med are the contracted providers of radiology services at LGH with i-TeleRAD during afterhours periods.
The coronial findings said that an i-TeleRAD radiologist missed the carotid dissection which appeared on about five of the 6500 images.
"Unfortunately, the injury to his left internal carotid injury was not detected by the reporting radiologist from the scans conducted on May 27 2021," Mr Webster said.
"Whether this was due to inexperience, time pressures, oversight, or some other reason is unknown," Mr Webster said.
The radiologist who the inquest heard may have been overseas-based was not called to the inquest.
The Department spokesman said that in line with standard clinical governance processes, the Department of Health's Statewide Medical Credentialing Committee credentialed radiologists practising in the public system.
"Credentialing is a peer review process of an individual's qualifications, suitability to practice and professional record. Each individual's credentials are renewed at appropriate intervals," the spokesman said.
The dissection was spotted by neurological staff after Mr Leary had suffered a severe stroke, which was irreversible by surgery.
In his findings, Mr Webster acknowledged that recruiting medical specialists was complex.
However, he said that the difficulties of offsite radiology identified by LGH staff could be overcome if the THS was prepared to pay attractive and competitive salaries.
The inquest heard that an offsite radiologist such as i-TeleRAD could be used between 4:30 pm and 8 am and before 4:30 pm if the onsite radiologist was too busy.
A practitioner told the inquest that he would prefer an onsite radiologist after hours because he would receive reports faster, particularly in cases involving an emergency like this one.
The practitioner said that an onsite radiologist after hours would enable face to face discussion.
"So not only would the delay be reduced the subsequent systems issues described may be reduced. This would have been very important in a case such as this one," Mr Webster said.
Nick Clark
I am the Supreme and Magistrates Court reporter for the Examiner for the past 18 months. My journalism career has clicked over 30 years and encompasses four different spells at Tasmanian newspapers.
I am the Supreme and Magistrates Court reporter for the Examiner for the past 18 months. My journalism career has clicked over 30 years and encompasses four different spells at Tasmanian newspapers.
