Canterbury DHB failed to action a CT scan when it was recommended the man get one an an X-ray showed a mass on his lung (file image). Photo: 123RF
Staff at the former Canterbury District Health Board failed to provide basic care for a man who presented to the emergency department multiple times for chest pain and later died of lung disease.
It has seen both a doctor and the DHB found in breach of the health code.
A report by the Health and Disability Commissioner said the man went to an emergency department several times with chest pain and was diagnosed with angina.
However, a chest X-ray taken at one of his visits showed a mass on his right lung.
A CT scan was recommended by the reporting radiologist, but it was not actioned and the man was not told of any abnormality.
The man was admitted to hospital over a month later where a CT scan was taken and he was sent for further investigations for suspected lung cancer.
Hospital staff failed to tell the man that a mass had been identified on his lung earlier and not been followed up.
An X-ray, performed on the same day as the biopsy, noted the mass in the man's right lung had increased in size from when it was first identified.
The man died from lung cancer the following year.
Prior to his death, he made a complaint to the HDC saying he was not fully informed about his condition and had no opportunity to question his treatment. He also said decisions were made without his knowledge.
The man also expressed concern that his frequent admissions to the ED could have been an indicator of the lung cancer and should have been investigated further.
Deputy Health and Disability Commissioner Deborah James found the physician's failure to act on the radiologist's report of the chest X-ray delayed the diagnosis of lung cancer for approximately four weeks.
James also noted that, despite several different clinicians in two different departments being aware of the failure to action the radiologist's report, no clinician took responsibility for ensuring that the man was informed of this error at the earliest opportunity.
"Systemic issues at Canterbury DHB constituted a failure to ensure that the man had all the information that a reasonable consumer in his circumstances would expect to receive," James said.
She also found the DHB in breach of the code, which relates to the right of the consumer to be fully informed.
James recommended the physician arrange for an audit of 50 radiology reports to identify whether significant abnormal findings are being actioned.
She also made a number of recommendations to Canterbury DHB, including that it introduce a further requirement that discharge summaries note any results that are still awaiting reporting.
James also recommended both the physician and Canterbury DHB write a formal apology to the man's family.