A woman in her 60s who died of cancer had her diagnosis delayed due to the Waikato DHB's failure to ensure she underwent further investigation following an x-ray that showed nodules in both her lungs.
The woman’s treatment was outlined in a recently released Health and Disability Commissioner (HDC) report, which found the Waikato District Health Board had breached her rights.
In February 2020, the woman visited a Waikato medical centre to have a lump on her neck checked.
An ultrasound later identified "abnormal lymph nodes" and a subsequent chest X-ray also “noted abnormalities”.
The doctor advised the woman to have another chest X-ray in six weeks since, at the time, her lump had shrunk, and her cough had lessened. Despite setting a repeat chest X-ray reminder, the doctor failed to follow it up.
Four days after the X-ray, the woman went back to her GP, complaining of upper back pain.
The doctor, who was concerned the pain could indicate metastatic cancer in the bone, discussed her concerns with an oncologist registrar at the hospital.
Five days later, she was admitted to the emergency department with pain in her back, lower chest, and abdomen. She also had nausea as well as reduced appetite and urine.
A chest X-ray at the time was initially "interpreted as indicating a lung nodule that had not changed".
However, the actual X-ray issued seven days later showed nodules in both lungs and cross-sectional imaging was recommended.
"Neither the medical centre nor the woman was alerted to the recommendations in the report."
In May 2020, the woman was readmitted to hospital and diagnosed with metastatic cancer with involvement of her lungs, lymph nodes, liver, and spinal and pelvic bones.
She died a few weeks later.
In her decision, Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the Waikato District Health Board (now Te Whatu Ora Waikato) had breached the woman’s rights "for failing to provide critical information to a consumer about her test results".
She said the organisation had failed to inform the woman and her medical centre that the chest X-ray result recommended further cross-sectional imaging.
Caldwell said: “While an earlier diagnosis may not have altered the course of the disease, it would have given the woman more time to contribute to a more meaningful management plan of her illness.”
"Te Whatu Ora had a responsibility to inform Ms A of the abnormal result that had been reported and the recommendation for further imaging.”
She also said the organisation should have “explicitly communicated to the medical centre that this additional imaging had been recommended".
"This omission was a further factor that contributed to the delay in diagnosis…I do not accept that Ms A should have been expected to follow up the repeat chest X-ray herself, as suggested by Te Whatu Ora."
She said the woman was given an “unclear diagnosis” following the emergency department X-ray and should have been seen by a senior clinician.
Caldwell did, however, acknowledge "systemic issues emergency departments face".
“Te Whatu Ora also continues to recruit radiologists and has increased film reporting capacity.”
She said the GP’s failure to follow up on a task reminder was a “factor that contributed to the delay in Ms A’s diagnosis”.
Caldwell recommended the doctor and Te Whatu Ora Waikato provide written apologies, and recommended that Te Whatu Ora Waikato review its electronic results policy and provide ED staff training on the updated policy.
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