The South Canterbury District Health board and Pacific Radiology has been found to have failed in caring for a woman who died from lung cancer.
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A report by the Health and Disability Commissioner Andrew Hill, stated that on 29 October 2010, a 61-year-old woman, known as Mrs A, was referred by her GP to the DHB's emergency department to look at a possible pulmonary embolism (blockage of the pulmonary artery in her lungs).
A chest X-ray and a CT scans found a "mass or mass like area of consolidation in the upper right lobe", and a follow up was recommended in six weeks, but it did not happen.
In Mr Hill's report, he said that in March 2016, Mrs A returned to her GP following three weeks of discomfort in her upper respiratory systems, and was prescribed antibiotics.
She returned to her GP again in May that year for having gall-bladder like symptoms and was this time referred for a semi-urgent ultra-sound, which was outsourced to Pacific Radiology the following month.
Pacific Radiology did not send an appointment letter to Mrs A until August 24, 2016, with an appointment date of 18 October 18 2016, nearly five months after the referral, the report said.
Mr Hill said Mrs A returned to her GP in September 2016 about her gall bladder like symptoms, and a private referral was made for later that month.
But Mrs A was diagnosed with lung cancer in November 2016 and died the following year, seven years after the initial complaint about her lungs.
Mr Hill said the lack of follow up in 2010, led to a missed opportunity for additional investigations and a likely delayed diagnosis of lung cancer.
He was critical that there was a breakdown in communication from the DHB both to the woman and her GP.
He recommended that the DHB apologise to the woman's family and provide an update on its outsourcing agreement with Pacific Radiology.
He also recommended to audit 50 imaging referrals outsourced to Pacific Radiology over the past six months, and review its policies regarding orientation, training, support and supervision of booking staff.