Woman with bowel cancer dies after poor reporting of CT scan

The health watchdog has found a radiologist's poor reporting of a CT scan may have delayed a bowel cancer diagnosis for a woman who died four months later.

The Deputy Health and Disability Commissioner Carolyn Cooper found the Whangārei radiologist failed to provide an appropriate standard of care when in 2018 his report of the scan had no mention of any abnormality.

The woman had been extremely ill and had a noticeable abdominal mass.

She was referred by her GP to the surgical team at Whangarei Hospital suffering pain, weight loss, vomiting, low iron and "a palpable abdominal mass".

Within two weeks she had blood tests and a diagnostic pelvic CT scan to check for malignancy.

The scan request form noted significant clinical concerns and a possible malignancy; "Three months of weight loss, two months of central abdominal pain. Malignancy?"

Health NZ said that no clinical information about vomiting or bowel obstruction was present on the CT request form.

The radiologist's report on the CT scan noted two minor issues but "no obvious malignancy". The radiologist recommended an ultrasound follow up in three months and the woman was advised by another doctor that her CT scan had not shown any obvious issues.

Several weeks later, the woman was readmitted to Whangārei Hospital severely ill with vomiting, diarrhoea, weight loss, and an unsteady gait.

The radiologist re-reviewed her abdominal and pelvic CT scan and picked up an abnormality, which was not noted in the initial review.

The radiologist updated the CT scan report with an addendum, which reported this abnormality and the need for further assessment. The radiologist did not document whether the abnormality had been communicated to the woman's GP.

Two days later, another doctor noted the addendum and an MRI scan discovered a cancerous mass causing a bowel obstruction.

The woman died a few weeks later.

The coroner found she had died of septicaemia due to a perforated bowel which had become obstructed by a tumour.

Cooper found the radiologist breached the code for the inadequate reporting of the CT report, including the failure to mention several important anatomical structures and whether these structures appeared normal within the report.

"I consider that the CT report was inadequate as it did not mention the gastrointestinal tract, the retroperitoneal structures, or the pelvic organs, and whether or not these appeared normal," she said.

"I am critical of the alert system and the process that was in place for documentation of addendums. Clear documentation of when and how the addendum was conveyed to the relevant parties could have prevented confusion in [the woman's] care and the subsequent delay caused by the confusion."

Cooper has made several recommendations, including that Health NZ provide a formal apology to the woman's whānau and that Whangārei Hospital's radiology department implements an "alerts" system to ensure that urgent or unexpected findings are received by the referring clinician in a timely and secure manner.