A man has died from cancer after a radiologist misread his CT scan, a report has found.
The man, who was in his 70s at the time, had a CT scan at Southland Hospital in January 2018 to investigate a mass in his liver.
The radiologist who interpreted the CT scan, reported that the mass wasn't cancerous.
But at a follow-up scan a year later, the man was diagnosed with cancer that had spread to other parts of his body, and he died as a result.
Health and Disability Commissioner, Morag McDowell, found the radiologist breached a number of rights in relation to the man's diagnosis but also in relation to another patient a year earlier.
Following an MRI in 2018, the radiologist reported a benign liver lesion in the other patient and stated no further follow up was required. In 2019, the man was admitted to hospital with abdominal pain.
An ultrasound found a substantial increase in the size of the original lesion. It was then discovered that the MRI read by the radiologist in 2018 was consistent with liver cancer. The man was subsequently diagnosed with terminal liver and pancreatic cancer.
McDowell says in relation to the 2018 incident, the radiologist failed to provide services with reasonable care and skill.
She said the radiologist did not correct an incomplete CT protocol when he became aware that the imaging was inadequate, which ultimately resulted in substandard interpretation of the CT scan.
McDowell says she considered the failure was an error attributable to the radiologist. She determined that Southern DHB did not breach the Code, although she identified several areas for improvement.
In relation to the 2017 incident, McDowell found the radiologist in breach of a number of rights including misdiagnosing the man’s liver lesion on an MRI as benign when in fact it was suspicious of liver cancer.
She said this was an error that fell "significantly below" the standard of care expected from a radiologist.
Also concerning the 2017 incident, McDowell found the Southern DHB breached Right 4(1) for an "unacceptable" delay in starting an internal investigation into the radiologist’s misread.
She has referred the radiologist to the Director of Proceedings to establish if legal proceedings should be taken.
The radiologist no longer works for Southern DHB.
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