File image. Photo: RNZ / Samuel Rillstone
Medical imaging services at Hawke's Bay Hospital were so fraught doctors had to take stopgap measures to shore them up while an investigation was ongoing.
This has been revealed after a senior radiologist blew the whistle for months on what has now been officially described as "unsafe" services.
Senior radiologist Dr Bryan Wolf told authorities in July 2023 it was criminal the review at Hawke's Bay had not been made public despite his and RNZ's efforts - RNZ made an OIA request for the review in May, but was blocked under whistleblowing laws.
Te Whatu Ora released the report on Monday, saying this was due to Wolf going public, and at the same time it had thanked and apologised to Wolf for having to go to such lengths.
Its interim chief clinical officer Dr Richard Sullivan said stopgap measures had to be taken while the external inquiry carried on, from December 2022 until April 2023.
"As the review was undergoing, it was clear that there was risk for our whānau in those communities and so we set up a task force team ... to look into doing some immediate stabilisation to try and reduce any risk and harm for our patients," Sullivan said on Monday.
Patients had suffered harm from years of services hamstrung by poor technology, the newly released report said.
"There is at least one case where a critical report was not delivered to the referrer leading to a 16-month delay in the diagnosis of malignancy," it said.
"Lack of a robust report delivery process is a widespread problem in NZ health settings."
Health Minister Ayesha Verrall said on Monday she had been advised that four cases had been referred for further investigation, including to the Health and Disability Commissioner.
Sullivan said Te Whatu Ora responded quickly in December 2022 to Wolf's alarms.
However, the agency had received an earlier alarm, in an internal memo in September 2022 about poor radiology IT systems across the million-strong central region.
This was leaked to RNZ and reported at the time, and is cited in the newly released review:
"The memo suggests that the likelihood of incidents occurring related to the first four risks is certain and that the impact on patients could lead to death or serious life-changing events.
"It is uncertain if this memo has been responded to formally, however, 'Tiger teams' were established in partnership between the Regional Radiology Steering Group and Regional Digital Health Services to look at the regional issues."
Dr Sullivan on Monday said: "My apologies, I'm not aware of that [September 2022] report".
Asked if Wolf was disciplined in any way for raising the alarm, Sullivan said no.
Wolf said he was not included in any Tiger team or in the oversight committee implementing the review's recommendations. He was "chastised" by a local executive shortly after lodging a report, Wolf said.
Sullivan said the oversight committee had no one on it from Hawke's Bay radiology. It had met four times, and now decided it needed someone local on it, he said.
The review found the same problems Wolf had documented, and said: "There is little evidence that clinician voice is adequately being responded to in a timely or comprehensive manner."
It made 18 recommendations, most of which Te Whatu Ora said it was implementing or had completed.
The system was not optimum but was now safe and stable, and more improvements were being made, Sullivan said.
This was echoed by the health minister, who said she had been kept advised on the situation "for several months".
However, internal communications RNZ has sighted show ongoing serious IT problems with reporting on patients' scans, including a lot of false alarms mixed up with real alarms about tumours or diseases spotted by scans.
The "clinical risk" from the central region's systems was "too high" due to lack of basic features, a Tiger team had advised. The region must begin looking for alternative platforms, it said.
Interviews with hospital staff combined to "paint a picture of staff exhausted by information systems that hamper their efforts to provide safe and efficient care to their patients", the review said.
Staff had been put off even reporting problems by them not being addressed properly for years - it is what the September memo said, too.
"This culture of learned helplessness extended to staff outside of the radiology department."
Te Whatu Ora said its legal advice was it had to protect Wolf's identity, so had refused to release the review to RNZ in June.
However, the review does not identify him as the whistleblower, and Wolf made clear he wanted full disclosure.
The radiology department had its international accreditation suspended in July.
In 2022, Te Whatu Ora played down the importance of this accreditation, after RNZ revealed several hospitals' radiology units, including the one at Hastings, had been tagged as "high risk" by International Accreditation of New Zealand (IANZ).
A week after the Hawke's Bay review was completed in April, Verrall visited the hospital.
In an email to health authorities, Wolf said he met Verrall, who "was unaware of my reports, so I provided her printed copies". He sent the reports to a wide group of health leaders, as well as writing a long warning letter to scores of senior medical officers in June.
He also wrote to the board and chair in April saying "each of you are now faced with ethical, moral and legal requirements" to give the public appropriate services and keep the public fully informed.
However, in late July he wrote again, saying that now the review had been done it was "gross negligence" that "the public were not guided in a way that minimised their exposure to risk".
There was "extreme discordance" between Te Whatu Ora's public statements and what it knew about the radiology systems, he said.
Verrall was asked on Monday what she was doing to determine if the shortcomings had occurred at other hospitals.
"I'm advised that while the software that was used in Hawke's Bay has been used at other hospitals, the particular combination of software and the way in which results were processed is not present in other hospitals," she said.
But the September 2022 memo described shared IT services letting down radiologists across hospitals from Hastings to Palmerston North to Wellington. Doctors in Wellington have said they, too, have struggled for years.
Te Whatu Ora has since done some upgrades, which doctors said was improving things gradually.