A doctor and Canterbury District Health Board are being reprimanded for delays in the diagnosis of a man's lung cancer which eventually killed him.
Canterbury DHB, now Te Whatu Ora Waitaha Canterbury, and the doctor were found in breach of the Code of Health & Disability Services Consumer’s Rights on Monday.
In 2019 the man, who was in his 80s at the time, went to the emergency department several times with chest pain and was diagnosed with angina. A chest X-ray taken during one of the admissions identified a mass on his right lung, and a CT scan was recommended by the reporting radiologist.
But a CT scan was never ordered and the man wasn't told about the mass until a month later when he was admitted again and a CT scan was taken.
At the later admission, he was told there would be further investigations to confirm suspected lung cancer, including a biopsy. But, he was not told the mass had been found in an earlier X-ray and not followed up.
An X-ray, performed on the same day as the biopsy, noted the mass in the man's right lung had increased in size from when it was first identified. The man died from lung cancer the following year.
In his complaint to HDC, the man said decisions were made without his knowledge concerning his condition and treatment.
He was not fully informed about his condition and had no opportunity to question his treatment. He also expressed concern his frequent admissions to the ED could have been an indicator of the lung cancer and should have been investigated further.
Deputy Health and Disability Commissioner, Deborah James, found the doctor's failure to act on the radiologist’s report of the chest X-ray delayed the diagnosis of lung cancer for approximately four weeks.
Deputy Commissioner James found the doctor in breach of Right 4(1) of the Code, which states that every consumer has the right to have services provided with reasonable care and skill.
She also noted that, despite several different clinicians in two different departments being aware of the failure to action the radiologist’s report, no one took responsibility for ensuring the man was told of the error at the earliest opportunity.
"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 in breach of Right 6(1) of the Code, which relates to the right of the consumer to be fully informed.
James recommended the doctor arrange for an audit of 50 radiology reports to identify whether significant abnormal findings are being actioned.
She made a number of recommendations to Canterbury DHB, including they:
- Audit compliance with the requirement to update discharge summaries with abnormal results that are received after a patient has been discharged, and compliance with sending the updated summary to the patient’s GP.
- Introduce a further requirement that discharge summaries note any results that are still awaiting reporting.
- Audit compliance with its current policy on open disclosure, in particular the requirement that (if possible) disclosure has been made within 24 hours, and any communication with the patient is documented in the patient’s record.
James also recommended both the doctor and Canterbury DHB write a formal apology to the man’s family.
