A public hospital radiologist has had to apologise to a woman's family for failing to accurately interpret a CT scan, after it was later found she had pancreatic cancer.
The radiology service where the radiologist worked has been told to implement a peer audit system across its service.
Deputy Health and Disability Commissioner Rose Wall today released a report finding the radiologist in breach of the Code of Health and Disability Services Consumers' Rights, for failures in the reporting of the CT scan.
Her report does not say where the case occurred or who the radiologist was.
In 2016, a woman with a history of abdominal pain presented to her GP feeling fatigued and having experienced significant weight loss.
The GP referred her to the public hospital for further investigation, and ordered a CT scan of the abdomen and pelvis.
The scan was performed and a radiologist read and reported on the scan remotely the same day.
The report documented his findings, noting some pancreatic atrophy and that no abnormalities were detected in the abdomen or pelvis.
Subsequently, no further investigations were ordered.
The woman continued to have further investigations owing to fatigue and ongoing changes in her weight and bowel habits, and the findings of those investigations were normal. She was referred back to her GP.
In 2017, the woman was seen by a gastroenterologist.
As the woman had abnormal blood test results, the gastroenterologist reviewed the CT scan that had been performed in 2016, and noted that pancreatic cancer was evident, and that this had not been reported at the time of the scan.
A further CT scan performed at the public hospital indicated the presence of metastatic pancreatic cancer.
Ms Wall found the radiologist failed to query the significance of the pancreatic atrophy he had reported and subsequently, failed to analyse the finding.
Ms Wall considered the radiologist did not interpret the scan accurately and initiate appropriate investigations following his reporting of the pancreatic atrophy.
Accordingly, Ms Wall found that the radiologist failed to provide services to the woman with reasonable care and skill.
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