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So far, Mawson is satisfied that in half of the cases, doctors got the results they needed promptly. However, a few dozen children have been the focus of further checks to make sure their doctors got abnormal ultrasound imaging results and followed up with them. One case, in particular, has resulted in further testing and followup.

Mawson said he has stepped away from radiology duties to lead the “incredibly labour intensive” review. The exercise he began a month ago has reassured him that the vast majority of radiologists have been fastidious in phoning referring doctors with abnormal findings and that doctors ordering such tests also did their due diligence.

But Mawson acknowledged that radiologists — like any humans — can make errors.

“We’re not perfect,” he said. “There’s no question this is a learning opportunity.”

Asked why there wasn’t a widespread notice sent to doctors or patients to alert them to the matter, Mawson said it could have been considered if his preliminary investigation had identified a large number of reports with concerning results that were never sent to doctors. Parents of children who have had an ultrasound (not any other kind of imaging test) at the hospital in the past 11 months should feel free to follow up with referring doctors to ensure results were received, he said. Likewise, any doctors concerned about whether they received patient records can also contact the hospital.

Once the investigation into all the patient files has been completed, a quality assurance review — either internal or external — will take place to get to the bottom of how and why the glitch occurred and how to prevent it from happening again, Mawson said.