A man’s lung cancer doubled in size after being missed despite nine scans over nine years in Southland Hospital.
In a Health and Disability Commissioner report released today, deputy commissioner Dr Vanessa Caldwell found he was not provided an appropriate standard of care.
The man had nine scans or x-rays between 2017 and 2022, when advanced stage four cancer was diagnosed and had spread to his spine.
The man’s lung tumour was first overlooked during a CT scan at Southland Hospital in 2017, then again during further scans in the following years.
Caldwell said there were several missed opportunities to identify the cancer and escalate his care appropriately.
An adverse event review conducted by Health NZ last year found that specialist radiologist staffing at Southland Hospital had an impact on the workload, with no radiology registrar on the Southland site to support the radiologists.
It also found reports were reviewed in a noisy environment where distractions could not be avoided and the opportunity for peer review was challenging with a lack of resourcing.
Radiologists were generalists rather than subspecialists and the reporting process was complex and both time and an appropriate environment was needed to complete reports and expertise in reviewing imaging was critical to reducing missed and incidental findings, the review said.
The man’s lawyer said he was now dealing with cancer which had metastasised to other parts of his body as well as brain bleeds and lesions in his spine and other bones.
“We note within the provisional report some of the excuses offered by [Health NZ Southern] in respect of the environment, work pressure, working conditions, etc, that the radiologists had to work in. With respect, that is not the patient’s fault… We note that multiple parties from different working environments, all of whom are deemed to be professional clinicians, failed [the man] significantly and repeatedly,” the lawyer wrote.
“[He], his family and friends are left wondering what his prognosis and outcome of treatment would have been, had the radiologists involved in this case been competent and had seen the clearly visible lesion in 2017 and ensured that the doctor/s looking after him actually followed up and that his case was made a priority.”
Caldwell said Health NZ had a responsibility to provide the man with an appropriate standard of care between 2017 and 2022.
In particular, she noted a doctor failed to identify the lesion in 2017 and Southland Hospital’s respiratory service failed to recognise it had grown in 2019. It had also failed to communicate with the man’s GP about the need for follow-up and failed to follow up on a scan in 2020 after a series of presentations to ED where the cause of his chest pain had not been identified.
Health NZ Southern said work is underway to provide staff with support to ensure a reasonable work-life balance to reduce stress and fatigue.
It will also reviewed peer-review requirements and discuss if they should be performed more frequently than annually.
The adverse event review made several recommendations, including the establishment of a business case for a radiology registrar in Southland Hospital, reviewing alternative options for managing day-to-day radiology processes to reduce distraction, reconfigure the working environment to allow the doctor reading images to have quiet protected time.
The commissioner recommended that Health NZ Southern provide a written apology to the man for the failings, update the commissioner on the implementation of the recommendations in the adverse event review, consider implementing more frequent peer-reviews, and use an anonymised version of this report to conduct training for its radiology and respiratory departments.
rnz.co.nz
