Untimely Diagnosis

Review the “Untimely Diagnosis” case summary on p. 267 of the book. If you were the responsible administrator, what would you do following this incident to prevent it from happening in the future? If you need to assume some facts in order to write your posts, please state your assumptions. What are the ethical issues in this case?
Do not do outside research for this. Instead, think about the steps you would follow, the sequence of such steps, and the individuals/departments you might need to involve.