Allegations of diagnostic delay and missed diagnosis are common in hospital medicine litigation, particularly in cases involving acutely ill inpatients. Dr. Joshua A. Ronen, MD, FACP, a board-certified internal medicine physician and active hospitalist, provides independent expert review of diagnostic-delay cases for plaintiff and defense counsel.
Diagnostic error is rarely a single missed finding. More often it is a process that unfolded over hours or days across multiple clinicians, shifts, and services — each of whom held part of the picture. Evaluating those cases requires reconstructing what was knowable at each decision point, not what became obvious once the diagnosis was known.
What Is Typically at Issue in Diagnostic Delay Cases
The applicable standard of care is fact-specific and jurisdiction-specific. In inpatient diagnostic-delay matters, expert analysis on both sides commonly centers on:
- Adequacy of the initial differential. Whether the presenting complaint and objective findings should have placed the eventual diagnosis on a reasonable differential at admission.
- Workup and its timing. Whether indicated testing or imaging was ordered, and whether the interval to obtaining and acting on results was reasonable.
- Response to abnormal or changing data. Whether new results, worsening vitals, or failure to improve prompted the differential to be revisited.
- Consultation. Whether specialty input was sought when indicated, and whether consultant recommendations were acted upon or documented as declined with reasoning.
- Handoffs and continuity. Whether pending workup, unresolved questions, and diagnostic uncertainty were communicated across shift and service transitions.
- Discharge decision-making. Whether the patient was discharged with unresolved abnormalities, pending results, or without adequate follow-up arrangements.
Cognitive factors recognized in the diagnostic-safety literature — anchoring, premature closure, diagnostic momentum carried forward from a prior clinician’s working impression — frequently appear in these records. Identifying them is not the same as establishing a departure from the standard of care, and a rigorous review keeps those questions separate.
Areas of Review
- Diagnostic timeliness and clinical decision-making
- Missed or delayed diagnosis in hospitalized adult patients
- Recognition and escalation of clinical deterioration
- Discharge planning and inappropriate discharge decisions
- Test result follow-up, including results returning after discharge
- Causation questions regarding whether earlier diagnosis would have altered the outcome
What the Record Review Covers
- Admission history and physical, and the differential documented at the outset
- Serial progress notes, tracking whether the working diagnosis was revisited as data accumulated
- Order timestamps compared against result and acknowledgment times
- Imaging reports, including preliminary versus final reads and any discrepancy between them
- Consultation requests, timing, and documented recommendations
- Nursing documentation of symptoms and concerns raised to the treating team
- Handoff and sign-out documentation across shifts and services
- Discharge summary, discharge instructions, and follow-up arrangements
Pending results at the time of discharge, and the mechanism (or absence of one) for closing that loop, are a recurring pivot point in these matters.
Common Allegations and Common Defenses
Frequently advanced by plaintiffs: failure to include the eventual diagnosis on the differential despite suggestive findings; indicated testing not ordered or ordered late; abnormal results documented but not acted upon; failure to reassess when the patient did not improve as expected; discharge with unresolved abnormalities or pending studies; inadequate communication of diagnostic uncertainty at handoff.
Frequently advanced by the defense: atypical presentation that did not reasonably suggest the eventual diagnosis; a working diagnosis that was reasonable on the information then available; testing appropriately deferred based on documented clinical reasoning; a condition that evolved after the relevant decision point; causation defenses regarding whether earlier diagnosis would have changed the outcome given disease stage or comorbidity; hindsight bias in retrospective review.
Why an Actively Practicing Hospitalist
Dr. Ronen’s review draws on his active hospitalist practice and his experience as a Physician Advisor to Utilization Management, where he evaluates medical necessity, documentation standards, and clinical decision-making. That second role is directly relevant here: it involves reading inpatient records specifically to assess whether documented reasoning supports the decisions made.
Diagnostic-delay cases turn on what a reasonable physician would have concluded from an incomplete picture at a specific moment. A reviewer in current inpatient practice can speak to how those judgments are actually formed — and to the difference between a diagnosis that was missable and one that was missed.
He offers medical record review, standard of care evaluation, written expert opinions, deposition testimony, and trial testimony. See his full qualifications or the scope of services offered.
Frequently Asked Questions
Does this cover emergency department diagnostic delays?
Dr. Ronen reviews the inpatient portion of care, including the admission decision and handoff from the emergency department. Opinions on emergency medicine practice itself are more appropriately offered by a board-certified emergency physician.
Can he opine on both standard of care and causation?
Within hospital-based internal medicine, yes — including whether earlier diagnosis would more likely than not have altered the clinical course. Questions requiring another specialty are identified as such.
Will he decline a case after review?
Yes, where the record does not support the retaining party’s theory or the matter falls outside his expertise. He also does not accept cases involving his current institution or its affiliated entities. Additional detail is available on the expert witness FAQ.
Related Case Types
- Sepsis Expert Witness — recognition, treatment, and escalation
- Failure to Escalate Care Expert Witness — clinical deterioration and delayed intervention
- Hospitalist Standard of Care Expert Witness — compliance with accepted hospitalist standards
- California Hospitalist Expert Witness — California licensure, practice, and in-state availability
- All hospital medicine case types
Contact Dr. Ronen or request a consultation to discuss a diagnostic-delay case.