A man who died from lung cancer could have been diagnosed four weeks earlier if an X-ray had been followed up on, a new report has revealed.
The man, referred to as Mr A, presented to an emergency department in Canterbury "several times" with chest pain through 2019, the Health and Disability Commissioner (HDC) found.
Mr A was in his 80s and had "a complex medical history".
Two X-rays in August that year did not identify any "suspicious masses".
Mr A's symptoms were diagnosed as angina and attributed to his heart problems.
But on August 29, when Mr A was again admitted to the ED, a chest X-ray identified a mass on his right lung.
A CT chest scan was recommended in the report, dated August 30 — however, Mr A was discharged "before the radiology reporting on his chest X-ray became available, and therefore his discharge summary did not include the findings of the reporting radiologist".
On September 2, the general medicine physician responsible for Mr A's care accepted the report in the Te Whatu Ora computer system — but they took no further action.
On October 6 that year, Mr A was back in hospital and another X-ray was taken. The mass had grown.
The radiology report asked: "I note CT chest was recommended on the prior x-ray report. Has there been CT of chest since that study?"
The next day, Mr A had a CT scan and he was told there would be further investigations to confirm suspected lung cancer.
"However, he was not told that the mass on his lung had been identified in an earlier X-ray and not followed up.
"The man unfortunately died from lung cancer the following year," the HDC said.
The complaint
Before he died, Mr A complained to the HDC about the incident.
"The man noted that decisions were made without his knowledge concerning his condition and treatment," the HDC said.
"He was not fully informed about his condition and had no opportunity to question his treatment. He also expressed concern that his frequent admissions to the ED could have been an indicator of the lung cancer and should have been investigated further."
The findings
Deputy Health and Disability Commissioner Deborah James said the physician's failure to act on the radiologist's report of the chest X-ray delayed the lung cancer diagnosis by about four weeks.
And despite other clinicians being aware of the failure, none "took responsibility" for informing Mr A.
"Systemic issues at Canterbury DHB constituted a failure to ensure that the man had all the information that a reasonable consumer in his circumstances would expect to receive," James said.
She found Canterbury DHB and the physician in breach of the Code of Health and Disability Services Consumer's Rights.
Among her recommendations, James proposed both the physician and the DHB write a formal apology to the man's family.
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