A lesion visible in a CT scan of a woman in her 60s was not reported by the radiologist at Hawke's Bay hospital. The woman was later diagnosed with lung cancer. Photo: RNZ / Tom Kitchin
A radiologist at Hawke's Bay Hospital failed to pick up a woman's lung cancer, which officials say was only a symptom of wider problems at the hospital.
A Health and Disability Commissioner review into the incident has been released today.
In 2016, a woman in her 60s at the time was referred to the region's radiology service for a colonoscopy, due to a strong family history of bowel cancer.
The woman had a CT scan and a lesion was visible, but it was not reported by the radiologist, and further investigation was not requested.
The lesion was not clearly identifiable in later x-ray images taken over the next three years and was not found until a CT scan in February 2020. This time, following further investigation, the woman was diagnosed with lung cancer.
Deputy health and disability commissioner Dr Vanessa Caldwell said the woman's lesion should have been reported back in 2016.
"I consider the failure by the radiologist to report this resulted in a missed opportunity for earlier diagnosis and treatment.
"I have taken into account Hawke's Bay District Health Board's acknowledgement that the radiology department was under-resourced in 2016, but the consensus of opinion is the lesion was visible on the CT scan in 2016 and should have been reported.
"The lesion was a significant finding, and the woman was specifically being screened for cancer in light of her family history. I consider the radiologist's scan report did not meet an adequate standard for care."
Caldwell said as a healthcare provider, the DHB was required to provide a safe and appropriate workplace environment, and ensure adequate processes to manage clinician workloads.
"The radiologist's error indicates broader systems and organisational issues at HBDHB.
"HBDHB has an obligation to provide services to consumers with reasonable care and skill, and ensure employees have the conditions necessary to perform their work to an appropriate standard.
"I consider the HBDHB's response to increasing radiology workloads was insufficient to support the team to maintain standards in the face of increasing demands on the service."
Caldwell recommended the DHB provide a written apology to the woman and her family and the radiologist should start a checklist reporting style and get familiarised with lung cancer.
She also recommended the DHB ensure staff were aware of the formal processes for clinicians to raise concerns about their working environment and review 30 random CT scans to improve reporting.
The DHB, now Te Whatu Ora Hawke's Bay told RNZ changes had been made since the incident.
"Radiologists now use an 'all images' approach to reading images, and the Radiology Department holds regular discrepancy meetings in which radiologists discuss and reflect on cases," chief operating officer Chris Ash said in a statement.
''The radiologist involved in this case is no longer employed at Te Whatu Ora Hawke's Bay and previously expressed their apologies to the patient and their whānau. Te Whatu Ora Hawke's Bay also expresses its apologies to the patient and their whānau for the level of care their loved one received."