A woman in her 70s died from a pancreatic tumour after it went undetected by her radiologist and district health board staff, the Deputy Health and Disability Commissioner (HDC) outlined in a report.
In the report released on Monday by Deputy Health and Disability Commissioner Deborah James, a radiologist was found to be in breach of the Code of Health and Disability Services Consumers’ Rights for failing to identify the pancreatic tumour in the woman’s CT scan.
According to the report, the woman had visited her GP with an array of symptoms, and was referred to a private general surgeon who referred her for a CT scan to investigate, after a gastroscopy and a colonoscopy showed no abnormalities.
After a scan in June 2018, the radiologist reported that the CT presented "unremarkable findings".
When the woman’s symptoms continued she was admitted to the public hospital and her CT scan was imported into the DHB and marked for "clinical review." However, the scan was not reviewed during her stay in hospital.
After being discharged from hospital, the woman’s symptoms continued and she was reviewed by a consultant physician and gastroenterologist.
They looked at her earlier CT scan and found that it showed a “mass suspicious of pancreatic cancer”, which followed with a diagnosis of advanced pancreatic cancer. The woman sadly died in 2019.
The Deputy Commissioner acknowledged that while “perception errors will occur”, it's her opinion "that the woman’s pancreatic mass and secondary signs should have been picked up by the radiologist”.
"I acknowledge that the woman’s scan, having been reported to the DHB as normal, may have influenced the clinician’s decision-making during her admission, particularly in regard to undertaking further investigations," said James.
In future, James recommended that the radiologist implement a "checklist" structured reporting style to provide a cue for each abdominal organ to be evaluated carefully, and familiarise himself with the various radiological manifestations of pancreatic cancer.
She also recommended the radiologist provide a written apology to the woman’s family.
SHARE ME