A man died from septic shock after a radiologist missed a "significant finding" in their scan according to Health and Disability Commissioner Morag McDowell.
McDowell released a report on the incident today which outlines how the man, aged in his eighties, had a CT scan at a public hospital to investigate abdominal pain and diarrhoea he was experiencing.
"The scan showed he had free gas in his abdominal cavity which indicated a bowel perforation. However, the radiologist missed this in the scan report and the man was discharged from hospital," the report reads.
"Sadly, a few days later he died as a result of septic shock due to the unrecognised bowel perforation."
McDowell concluded that due to the radiologist’s failure to identify free gas in the abdomen on the CT scan, the opportunity to consider surgical review and treatment options was missed.
"The report highlights the importance of radiologists identifying significant findings on CT scans," McDowell said.
She recommended that the radiology service provide an update on the level of internal audit of its radiologists, and the radiologist provide a written apology to the man’s family.
The report states that the radiologist has, "reflected on these events and has completed appropriate training and audits of abdominal scan reporting."
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