Alrifai v Australian Capital Territory [2022] ACTSC 48

INITIAL JUDGMENT:

Delay in diagnosis of pancreatic cancer

1. The injured plaintiff, Mrs Alrifai was unfortunately unsuccessful in this case as the Australian Capital Territory (ACT) Supreme Court found that the delay in diagnosis and treatment of her pancreatic cancer did not cause her injuries.

2. Mrs Alrifai had numerous presentations and admissions to Canberra hospital, starting in December 2017 when she had chest pain. Eventually in November 2018 the cancer was diagnosed, she surgery to remove the tumour, adjuvant chemotherapy but later developed recurrence and at the time of the hearing she was terminal with a life expectancy of 18 months.

3. Mrs Alrifai alleged that the hospital breached its duty of care in January 2018 by failing to refer her for a surgical opinion. The hospital denied this but admitted that it breached its duty of care later in time, in April 2018 but said the delay of 7 months made no difference to her outcome and did not cause her any injury.

4. During Mrs Alrifai’s admission from 1 to 3 January 2018 an abdominal CT scan was done which was reported as demonstrating features consistent with acute pancreatitis without complications. Pancreatitis is an inflammation of the pancreas and the two most common causes of pancreatitis are gallstones and alcohol. The doctor who reviewed her in January 2018 was aware that pancreatic cancer is the cause of pancreatitis in about 1% of cases. Based on the clinical presentation of abdominal pain radiating and the investigation results the doctor diagnosed acute pancreatitis . An ultrasound excluded gallstones as the cause of pancreatitis.

1. Mrs Alrifai alleged that CT scans in January and April 2018 showed a discrete mass in the pancreas which was confirmed on the endoscopic ultrasound in April 2018 during which a biopsy of the cells taken by fine needle aspirate from the tail of the pancreas were reported to show overall features of pancreatitis and with a small amount of cellular material showing worrying architectural and cytological changes. She alleged that the findings in April 2018 warranted a surgical referral leading to earlier removal of the tumour.

Breach of duty

6. Although the court documents filed for Mrs Alrifai alleged the failure of the hospital to consider a differential diagnosis of pancreatic cancer on and from January 2018, her barrister did not suggest that there was any positive evidence proving that the hospital failed to diagnose the cancer in January 2018.

7. The court did not accept the evidence of Professor Morris, surgeon specialising in oncology and Professor Fox, retired haematologist and oncologist that the CT scans in January and April 2018 showed a significant abnormality and that the treating doctors failed to see evidence of a mass on the CT scans given the overwhelming evidence to the contrary and that Professor Morris had no training in the reading of CT images.

8. The court found that in January 2018 when a diagnosis of pancreatitis was made, investigations were commenced to ascertain the cause of the condition and one of the possible causes was a tumour. In this context a differential diagnosis was pancreatic cancer. There was evidence by Dr Drini that during the admission in April 2018 pancreatic cancer was definitely a differential diagnosis.

1. The court found that the hospital did not breach its duty of care by failing to arrange a surgical opinion in January 2018. The court declined to find that the hospital failed by 26 April 2018 to have made or properly considered a differential diagnosis of pancreatic cancer.

Causation / risk of recurrence

1. Mrs Alrifai had to prove that she suffered injury due to the failure to obtain a surgical opinion in April 2018, resulting in the delay in in diagnosing the pancreatic caner before November 2018. The court declined to find that if earlier surgical consultation had occurred in April 2018 this would have changed the course of investigations or treatment, or that she would have undergone surgery any earlier.

1. The court preferred the evidence of the defendant’s expert medical oncologist, Dr Burge over that of Professor Fox and Professor Morris as he had significantly more expertise in pancreatic oncology. Professor Burge’s subspecialty was in gastrointestinal medical oncology and he treated many patients with pancreatic ductal adenocarcinoma. In contrast, Professor Fox had no clinical experience treating patients with cancer since 2006 and was not a specialist in pancreatic cancer before that.

1. The court accepted Dr Burge’s evidence that it was not likely that she would have avoided a terminal diagnosis if the pancreatic cancer had been diagnosed in April 2018 instead of November 2018. Dr Burge accepted the evidence of Professors Morris and Fox that the tumour probably grew in size during this period but that it was far too simplistic to conclude that patients with larger tumours have a poorer survival simply because they were diagnosed later. Tumour size is just one of many prognostic factors.

1. The court also accepted that Mrs Alrifai would not have avoided adjuvant chemotherapy with earlier diagnosis as it is routinely offered after surgery for pancreatic adenocarcinoma, regardless of stage, as all patients are considered to be at sufficiently high risk of recurrence to warrant chemotherapy.

Claustrophobia

1. Mrs Alrifai also alleged that the hospital failed in March 2018 to offer treatment strategies such as administering a sedative when she declined to have a  MRCP, a special kind of MRI test (Magnetic resonance cholangiopancreatography) at the hospital as she found the equipment too claustrophobic. The MRCP took place on 13 April 2018 and did not identify any pancreatic pass. The court declined to find that an earlier MRCP would have made a difference to her management, our outcome.

COURT OF APPEAL JUDGMENT

Alrifai v ACT [2024] ACTCA 13

1. Mrs Alrifai appealed the initial judgment of the ACT Supreme Court on the basis that the judge had made an error in finding that the hospital’s breach of duty of care in April 2018 did not cause her injury.

1. The ACT Court of Appeal upheld the initial judgment and also found that Mrs Alrifai’s injuries were not caused by the hospital’s breach of duty of care. Accordingly, her appeal was dismissed and she was unsuccessful.

The full judgments can be found online:

• For the initial judgment: https://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/act/ACTSC/2022/48.html
• For the Court of Appeal decision: https://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/act/ACTCA/2024/13.html?context=1;query=Alrifai%20v%20ACT;mask_path=

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If you or someone you know has been injured due to medical negligence  medical negligence including any delay in diagnosis of pancreatic cancer you should contact Stacks Goudkamp on 02 9237 2222 for a confidential discussion to see if we can help you on a “no win, no fee” basis. To arrange a free consultation with a medical negligence lawyer call us or submit an online enquiry.