Ms. T, a 28-year-old African American, went to her HMO about pain in her calf and ankle. Suspecting a muscle tear, her nurse practitioner, Mr. N, referred her to a radiology practice for an x-ray of her ankle and a Doppler ultrasound of her calf. He also set up an appointment to see her at the end of the week.

Ms. T underwent the tests the following day. “Something looks off here,” the ultrasound technician thought to himself.

After telling Ms. T to call the HMO for her results, he took the images to the radiologist, Dr. C. She diagnosed deep venous thrombosis (DVT), putting Ms. T at risk of a pulmonary embolism.

Dr. C immediately called Mr. N’s office. After working her way through the automated menus, she finally reached a receptionist, identified herself as a radiologist, and stated that she needed to speak to Mr. N urgently.

The receptionist put Dr. C on hold while she tried to locate the NP. Dr. C stared at her wall clock and watched the minutes tick by. Slamming the phone’s buttons and yelling “Hello! Hello?” into the receiver had no effect.

Finally, the radiologist hung up in frustration. Rather than risk another irritating delay by calling back, she decided to fax her report and gave it to an assistant for transmission.

Meanwhile, Ms. T called Mr. N as the ultrasound technician had instructed and was told that her results weren’t back yet. Later that week, Ms. T had a child-care emergency and missed her follow-up appointment with Mr. N. She assumed that if the results had come back, he would have called.

Two days later, she was found dead from a pulmonary embolism. It was only after her death that Dr. C’s report was discovered at the bottom of a box of incoming faxes, where it had languished for almost a week.

Ms. T’s distraught family hired a plaintiffs’ attorney and sued both Dr. C and Mr. N for negligence. The clinicians hired separate attorneys who encouraged each to blame the other.