Ethics · Advanced · Medical Error

Addressing Misdiagnosed Pneumonia

Practise this PLAB 2 ethics station on Misdiagnosed Pneumonia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a general practice clinic. You are seeing Mrs Sana Bhatia, a 73-year-old woman. Three weeks ago she was diagnosed with viral bronchitis by her GP and prescribed supportive care only. Last week she was admitted to hospital with pneumonia and has only just been discharged. She has called the practice requesting an urgent appointment to discuss what happened. The initial diagnosis was incorrect. Please address her concerns, explain the misdiagnosis, discuss what should have happened, and plan ongoing management.

Background notes: PMH: Hypertension (well-controlled), Osteoarthritis bilateral knees (age-appropriate, mild)

What this station tests

  • Duty of candour for a missed radiological finding: honest disclosure of what was missed
  • Not diagnosing cancer prematurely: the shadow needs CT characterisation first
  • Incident reporting: Datix for the missed finding
  • Acting urgently now: the delay has happened, but prompt action from here improves outcomes
  • Supporting complaint while continuing care

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Mrs Bhatia (73) was treated for a chest infection 3 weeks ago. CXR reviewed retrospectively shows a lung mass missed initially. She needs to be told about the finding and the delay. Open with: 'Mrs Bhatia, I need to discuss something important about your chest X-ray. I want to be completely open with you.'

Core approach

Duty of candour. 'When your chest X-ray was reviewed again, a shadow was found that was not identified in the initial report. This shadow needs urgent further investigation.' Be honest: the finding was missed, and she deserves to know. Do not minimise or hide this.

Explain next steps. CT scan urgently to characterise the shadow. It may be benign (post-infectious change) or may need further investigation (possible malignancy). Do not diagnose cancer at this stage. 'We need more information before we can say what this is.'

She will be frightened and may be angry about the delay. Both responses are valid. 'I understand this is very worrying, and I am sorry the shadow was not identified sooner. We are acting on it now as quickly as possible.'

Closing and safety netting

Urgent CT arranged. If suspicious: 2-week-wait referral. Incident reported (Datix). If she wants to complain: PALS. Ongoing support regardless of complaint. 'I will make sure this is followed up quickly and that you are kept informed at every step.' Follow-up: CT result within days.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Supporting)

Scores well: Finding explained. Next investigation planned. Timeline acknowledged.

Costs marks: Hiding the finding.

Domain 2 (Primary focus)

Scores well: CT arranged urgently. Datix filed. PALS offered. 2WW if suspicious. Follow-up within days.

Costs marks: Not investigating. Not reporting. Delayed follow-up.

Domain 3 (Primary focus)

Scores well: Honest disclosure. Apologising for the delay. Acknowledging her fear and anger. Acting quickly now.

Costs marks: Hiding. Defensive. Not acknowledging the error.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Hiding the missed finding: duty of candour is a legal and professional obligation
  2. Diagnosing cancer from a CXR shadow: CT is needed for characterisation
  3. Not reporting the incident: missed radiological findings require formal incident reporting

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How do I structure my approach to this misdiagnosed pneumonia consultation?

Mrs Bhatia (73) was treated for a chest infection 3 weeks ago. CXR reviewed retrospectively shows a lung mass missed initially. She needs to be told about the finding and the delay.

What does a strong performance look like to the examiner in this station?

Strong performances show: Finding explained. Next investigation planned. Timeline acknowledged. Weak performances: Hiding the finding.

What is the biggest pitfall in this misdiagnosed pneumonia station?

Hiding the missed finding: duty of candour is a legal and professional obligation. Another frequent error: Diagnosing cancer from a CXR shadow: CT is needed for characterisation.

How should I prepare for misdiagnosed pneumonia if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Not diagnosing cancer prematurely: the shadow needs CT characterisation first. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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