The Health and Disability Commissioner has found a radiologist failed to spot malignant growths on a woman's lung.
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The woman, in her thirties, first underwent a surveillance CT scan of her chest and abdomen in 2019, delivered by a radiology service contracted by the District Health Board.
However, following a further scan seven months later, the woman was diagnosed with colorectal liver metastases in her lung.
Deputy Commissioner Deborah James said while perceptual errors do occur in radiology, there was unanimous agreement that the lung nodule was visible on the earlier scan.
"The nature of radiology reporting is complex and it is widely accepted that due to perceptual errors, radiologists may from time to time miss what, with hindsight, may be obvious."
James said the woman's lung lesion should have been detected by the radiologist when he reported the scan earlier in 2019.
She found the radiologist failed to provide services with reasonable care and skill.
"I consider that a radiologist in these circumstances exercising reasonable care and skill would have detected the lung nodule on a scan," she said.
James said she was pleased the radiologist acknowledged his error and apologised to the woman.
"The radiology service is also instituting a programme to help manage a radiologist's workload and for image review and interpretation.
"The programme will incorporate a peer review module, which will require a percentage of all reported studies to be reviewed by another radiologist for quality control purposes."
The woman was immediately referred to the cardio-thoracic and oncology department at her DHB for further assessment and treatment.
She underwent surgery in early 2020.