When the Diagnosis Was Right but the Message Never Arrived

A CT angiogram does not treat anyone. Neither does a radiology report sitting in a chart. Treatment starts at the moment a clinician who can act receives the finding, understands what it means, and does something about it while doing something still helps. Everything before that is potential.

That gap between knowing and acting is what a Georgia jury spent weeks examining in Buckelew v. Womack, and it is the reason the case matters well outside Georgia. The verdict came in October 2022. The Court of Appeals affirmed it in March 2025. Buckelew v. Womack, 374 Ga. App. 711, 913 S.E.2d 789 (2025).

What happened at North Fulton Hospital

Jonathan Buckelew was thirty two. On the afternoon of October 26, 2015, he had seizure-like activity and became unresponsive during a chiropractic neck adjustment, and he arrived by ambulance at North Fulton Hospital, a primary stroke center. Within twenty minutes the emergency physician ordered a CT scan and a CT angiogram of his head and neck. Stroke went on the list of possible diagnoses.

Then the picture came apart in transit. The emergency physician suspected meningitis or encephalitis and called the on-call neurologist about those possibilities. By the neurologist’s account, the call did not include the chiropractic manipulation, the second seizure-like event, the CT angiogram, or any suggestion of an arterial dissection. Buckelew stayed overnight. An MRI the next morning finally showed the dissection and a brain stem stroke, and by then, in the court’s words, the “window of opportunity for a mechanical thrombectomy had passed.”

He has locked-in syndrome and requires constant care. The jury awarded $75 million, roughly $9 million in past medical expenses, $20 million for future care, and $46 million for pain and suffering, and apportioned sixty percent of the fault to the emergency physician and forty percent to the radiologist.

Read the record and the case is not really about a missed image. It is about whether anyone assembled the pieces into a clinical picture and moved that picture to a person who could act on it. The plaintiff’s emergency medicine expert testified that the physician grossly departed from the standard of care by not telling the neurologist about the chiropractic visit, the CT angiogram, and the possibility of dissection, and also faulted the failure to request an in-person evaluation, the failure to call back after the second event, and inaccurate documentation of symptoms.

One case does not make a doctrine, but the claims data is pointing the same direction

Communication has always shown up in malpractice files. What appears to be changing is its rank. In a case like this one, the communication failure is not context. It is the spine of the theory, the thing that turns scattered acts and omissions into one story a jury can follow.

Candello, the claims data collaborative run by CRICO, put numbers to it in late 2025. Reviewing tens of thousands of asserted and closed medical professional liability cases from 2014 through 2024, its report Malpractice Risks in Communication Failures: A 10-Year Follow Up found communication-related factors in forty percent of asserted cases, up from roughly thirty percent in the 2009 to 2013 data of its 2015 report. Those cases carried thirty nine percent greater odds of closing with an indemnity payment. Average indemnity was almost identical to cases without a communication issue, about $420,000 against $418,000, but average defense expenses ran higher, roughly $79,000 against $64,000. Candello also found these breakdowns more common in ambulatory settings than inpatient ones, and provider-to-patient failures rising faster than provider-to-provider failures.

The expense gap is the tell. Communication cases cost more to defend because someone has to reconstruct phone calls, establish who held which piece of information at what minute, reconcile two honest and incompatible recollections, and pull records out of several systems that were never designed to be read together.

None of that means courts have adopted a new standard of care. It means something more useful to a practicing lawyer. Communication problems now appear often enough, and pay often enough, that treating them as a secondary allegation is leaving value on the table.

Why modern care delivery keeps producing these cases

A patient can pass through an emergency physician, a radiologist, an on-call neurologist, a hospitalist, a physician assistant, several nurses, and an outside stroke center inside a single shift. The information moves by phone call, dictated report, secure message, automated alert, progress note, pager, and electronic task list. Every additional channel is another place where the duty to act can quietly fail to attach to anyone.

The question in the next wave of these cases is less about who first saw the abnormality and more about who owned the job of turning that observation into treatment.

Radiology sits at the center of the problem

Interpretation and communication are two separate professional acts in radiology, which is why the failure mode is so easy to see there. A radiologist can read a study correctly and still communicate it too slowly. A report can post to the chart without reaching the person who has to act. An alert can land in an inbox nobody opens. A follow-up recommendation can appear in the impression with no human being assigned to carry it out.

The American College of Radiology opens its current communication practice parameter with the flat statement that effective communication is a critical component of diagnostic imaging, and it calls for communication outside routine reporting channels, promptly, when a finding may require immediate or urgent intervention. ACR Practice Parameter for Communication of Diagnostic Imaging Findings (rev. 2025).

The ACR also says its parameters are educational and are not intended to set a legal standard of care. Both sides tend to overread that sentence. A plaintiff cannot wave the parameter around as though it were a statute. A defendant should not assume the disclaimer makes it disappear either, because depending on the jurisdiction and the expert foundation, it can still help a jury understand what communication methods existed, what the profession expects, and whether a hospital policy was reasonable.

Closed-loop communication is where the evidence lives

Sending is not closing. Janice Kwan and Hardeep Singh describe closed-loop communication as requiring both the transfer of information and “acknowledgment of receipt by the recipient.” Janice L. Kwan and Hardeep Singh, Assigning Responsibility to Close the Loop on Radiology Test Results, 4 Diagnosis 173 (2017). That distinction decides cases. A sent message proves transmission. It does not prove receipt, comprehension, or acceptance of responsibility.

Hospitals that have taken the problem seriously build for that difference. Brigham and Women’s Hospital, in work supported by the Agency for Healthcare Research and Quality, deployed an alert notification system for critical imaging results that recorded whether the responsible clinician acknowledged the result, monitored alerts that went unacknowledged, and fed that back to radiologists and referring providers. Documented communication of critical results improved. The design principle is what matters for litigation: a passive report depends on somebody happening to notice it, while a closed system names an owner and keeps a record of whether the owner accepted the handoff.

Buckelew is a warning about pleading institutional theories

Communication cases invite scrutiny of the hospital, not just the clinician. Sometimes the failure is one doctor’s judgment. Often it also reflects a system that never specified who calls whom, how fast, what happens when the first recipient does not answer, and who watches the alerts nobody closed.

Buckelew contains a hard lesson on that point. The plaintiff tried to reach theories about training on the hospital’s stroke protocol, enforcement of the intensive care admission policy, management of information technology, and CT image processing. The Court of Appeals held those direct institutional theories were not fairly included in the controlling pretrial order, so they could not be tried.

Plaintiffs should read that ruling as a checklist. A complaint built on vicarious liability for nurses and employed physicians may not preserve claims about defective alert architecture, inadequate training, unsafe escalation rules, an incomplete stroke protocol, or poor integration between the radiology system and the electronic health record. Name the institutional theory in the pleadings, in the expert disclosures, and in the pretrial order. Do not assume that general proof of a communication failure will open the door at trial.

Defense counsel should run the same analysis in reverse. A hospital can have a strong answer on vicarious liability and real exposure on how it designed or enforced its communication process. Find out early whether the written policy matched actual practice, whether staff were trained on it, whether the technology behaved as advertised, and whether an earlier incident had already exposed the same gap.

Documentation, metadata, and the version history

Whose account survives usually depends on the record rather than the witness. In Buckelew, the timing of additions to the emergency department record became a trial issue, and the court upheld impeaching a defense expert with a prior statement he had made on a podcast about later additions to medical notes. The broader point is not the unusual evidentiary fight. It is that metadata, version histories, signature times, access logs, and message acknowledgments will carry more weight than anyone’s memory of a phone call from four years earlier.

A communication breach is not causation

This is where otherwise compelling cases die. The plaintiff has to connect the missing communication to a specific treatment decision, then connect that decision to a probably better outcome.

Buckelew’s experts built that bridge. The interventional neurology expert worked through the arrival time, the patient’s age, his collateral blood flow, his eligibility for thrombolytic treatment, and the availability of mechanical thrombectomy, and testified that timely treatment more likely than not would have left him essentially independent. The Court of Appeals found the opinion sufficient, noting that medical causation cannot rest on speculation or possibility.

Expect every one of these cases to turn on the same sequence. What information was missing. When should it have arrived. What would the recipient probably have done with it. How long would that action have taken. Was the patient still eligible for the treatment at that point. Would the treatment probably have changed the outcome.

Skip a link and you have a moving story without legally sufficient causation. On the other side, a defense that argues only about whether a message was sent may be walking past a much better argument about treatment eligibility, timing, or probable outcome. The communication timeline and the causation timeline get built together, because in these cases they are the same exhibit.

What to do first in a suspected communication case

Before the first significant deposition, build a minute-by-minute communication map. For each clinically significant finding, record who knew it first, the time they knew, how it was communicated, who was supposed to receive it, whether anyone acknowledged it, whether anyone escalated, and what treatment consequence followed the delay.

To build that map you need native data, not printouts: electronic health record audit trails, radiology system access logs, report version histories, critical result alerts, secure messages, paging records, telephone logs, staffing assignments, transfer center records, and the policies actually in effect on the date of care. When the dispute is about timing, screenshots and printed charts are not evidence of timing.

Plaintiffs should preserve individual and institutional theories expressly in the complaint and the pretrial order. Defense counsel should lock down the same electronic evidence immediately and identify the clinician who owned the result at each stage. Both sides should ask every witness the same plain questions. What did you know. When did you know it. Who did you tell. How do you know the message was received. What was supposed to happen next.

Done properly, that exercise tells you which case you actually have: a misdiagnosis, a correct diagnosis nobody communicated, a failed handoff, a defective hospital process, or a delay that changed nothing. That distinction is where liability begins, and where a defense either holds or breaks.

How Med Legal Pro helps

Communication cases live in the chart metadata and in the handoffs, and they need experts who can read both. Med Legal Pro reviews the complete record, builds the communication and treatment timeline, identifies documentation gaps and late entries, and matches attorneys with emergency medicine, radiology, neurology, nursing, and hospital administration experts trained under our C.L.E.A.R. Method. We also provide case merit assessments before you commit to litigation.

Call 844-633-5345 or submit a case at medlegalpro.com/submit-a-case.

This article is for informational purposes and is not legal or medical advice.