A district health board has been asked to review its radiology department, after a teenage brain cancer patient's MRI scan was misread and she later died.
File image of a MRI scan. Photo: (By Bobjgalindo - Own work, GFDL)
The teenager had been diagnosed with a high-risk brain tumour - medulloblastoma - six years earlier and underwent neurosurgery to have it removed.
Medulloblastoma is the most commonly occurring type of brain cancer in children.
Health and Disability Commissioner Anthony Hill said the teenager had regular follow-up checks after her original tumour was discovered, but during one in 2014 the radiologist failed to recognise the recurrence of a tumour.
He said the failure to recognise the tumour was down to human error, but it was impossible to know if the outcome for the young woman would have been different if it had been found earlier.
The radiologist who missed the lesion was not overworked or stressed, despite working for a DHB and a private medical employer, he said.
"A surveillance scan in 2015 resulted in the tumour being found but when they checked back on the 2014 MRI it was evident the lesion was on that scan and ought to have been picked up at that time," he said.
"We had a known disease, that was known to be a threat for recurrence, it occurred in a way that was not wholly unexpected and ... and it was missed on the scan that was designed to pick it up.
"Any recurrence of this particular kind of tumour was going to create very serious health concerns for this young woman, so it's really not possible to predict what might've happened," he said.
Mr Hill recommended the radiologist's DHB, which has not been named in the report, review its radiology staffing levels, management and timetabling.
"This young woman has now passed away and her health experience was an extremely sad and grievous journey ... it's been a tragedy for this family," he said.
"I've asked that the services do review and ensure that they have got consistent availability of staff, that they have got consistent availability of second reads [opinions].
"The services have built in that ability to have a second read but I've asked that in addition to checking their workforce supply and management and timetabling that they are very clear that the second read opportunity is also known about and accessed."
A report found the radiologist, who apologised to the family, failed to provide a reasonable level of care to the young woman.
The radiologist in question was not referred for disciplinary action, Mr Hill said.