Human error and a failure by the former Hawke's Bay District Health Board to properly manage increasing demands on clinician caseloads “resulted in a missed opportunity for earlier diagnosis and treatment” after a radiologist failed to identify a lung lesion on a woman’s CT scan.
It comes after a woman in her 60s was referred to the HBDHB Radiology for a screening colonoscopy due to a strong family history of bowel cancer.
The abdominal CT scan, which included images of her lung bases, was carried out on November 4, 2016. While a lesion was visible in the right lower lung, it was not reported by the radiologist, and further investigation had not been requested.
The lesion was not clearly identifiable in subsequent x-ray images taken in 2016, 2017, and 2018, and was not identified until a CT scan of her abdomen and pelvis were carried out in February 2020. She was later diagnosed with lung cancer.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell acknowledged in her decision, released today, that "radiology reporting is a complex perceptual and cognitive task, and some degree of human error is unavoidable”, adding that the working conditions “may increase the risk of error".
"However, as stated by this Office previously, acceptance that errors of perception occur in a small but persistent number of radiology interpretations is not determinative in assessing whether the standard of care has been met in a particular case," she said.
"The woman’s lung lesion was visible on the CT scan of 4 November 2016, and should have been reported."
Caldwell said the failure by the radiologist “resulted in a missed opportunity for earlier diagnosis and treatment” and "indicates broader systems and organisational issues at HBDHB", now known as Te Whatu Ora Te Matau a Māui Hawke’s Bay.
"I have taken into account HBDHB’s acknowledgement that the Radiology Department was under-resourced in 2016, but the consensus of opinion is the lesion was visible on the CT scan in 2016 and should have been reported.
"The lesion was a significant finding, and the woman was specifically being screened for cancer in light of her family history. I consider the radiologist’s scan report did not meet an adequate standard for care."
She found the HBDHB in breach of the code over its failure to maintain standards by managing increasing demands on its service.
"HBDHB has an obligation to provide services to consumers with reasonable care and skill, and ensure employees have the conditions necessary to perform their work to an appropriate standard," she said.
"I consider the HBDHB’s response to increasing radiology workloads was insufficient to support the team to maintain standards in the face of increasing demands on the service."
Caldwell recommended the HBDHB and the radiologist provide a written apology to the woman and her family, and that the radiologist implement a checklist structured reporting style and familiarise himself with the various radiological manifestations of lung cancer. She also gave recommendations for the HMDHB around staff raising concerns, audits, and reporting processes.
The doctor, who was not named, told the HDC of their devastation at the stress caused.
"I was personally heartbroken to be informed of these. My role as a doctor is always to protect my patients and help them in any way possible and I regret that I missed opportunities to do so in this case."
SHARE ME