The Health and Disability Commissioner has found a woman died from lung cancer after a doctor missed an opportunity to diagnose her three years earlier.
An abnormal mass on the woman's lung was detected after an x-ray (file picture). Photo: 123rf
A report by Commissioner Morag McDowell found a Waikato Hospital emergency department doctor and Waikato District Health Board (DHB) breached the Code of Health and Disability Services Consumers' Rights (the Code).
The woman, who was in her sixties, went to the emergency department (ED) in March 2017 with stomach pain and nausea, it said. After an x-ray, the radiology report described an abnormal mass on her lung, but the doctor overlooked the comment.
Nothing was done until the woman visited the ED again three years later, when the comment on the report was noticed. Around that time, the woman was diagnosed with lung cancer.
"As a result of the delay, the opportunity to diagnose cancer at an earlier stage was missed," the report said.
The clinician was found to be in breach of the code for missing the radiologist's comment about the abnormal mass and failing to take any follow-up action.
Waikato DHB also breached the code for waiting 11 days before sending the x-rays for radiology reporting, which "increased the possibility of harm to the woman".
While McDowell acknowledged the pressure radiology services were under due to increase in demand, workforce shortages and recruitment challenges, she said healthcare consumers had the right to expect x-rays to be read sooner than that.
"That such delays are common does not excuse the delays, and I am concerned that if a culture of tolerance of unacceptable delays develops, this will become normalised and patients will be put at risk," McDowell said.
"The passage of time between seeing a patient and reviewing a radiology report does not support good clinical decision-making, and the timely reporting of radiology results is a critical systems issue."
McDowell was concerned the woman's general practice, which was sent a copy of the x-ray radiology report, also missed the abnormal x-ray result.
"Clear communication between ED clinicians and GPs, and a shared understanding about responsibility for the follow-up of test results is essential to patient safety," she said.
In the report, the ED doctor said this was the first time in many years of practice where he had misread a report and not acted on comments or recommendations, or failed to follow up on an abnormal or significant test result.
"I believe fatigue is likely to have been the reason why I overlooked the comments about the mass and recommendation by the radiologist and I deeply regret this," he said.
He was extremely sorry for his mistake and the significant impact this had had on the woman and her family, he said.