[ad_1]
In a decision by Deputy Commissioner Carolyn Cooper, a
radiologist and a urologist were found in breach of the Code
of Health and Disability Services Consumers’ Rights (the
Code) as they did not recommend or arrange appropriate
follow-up for a woman diagnosed with cancer, thereby failing
to provide services with reasonable skill and
care.
The woman was diagnosed with a renal cell
carcinoma (RCC) requiring surgery to remove her kidney.
Before the surgery, the woman had a CT scan to assess the
stage of the cancer. In reporting the CT scan, the
radiologist identified an abnormality in the woman’s lung
but did not make a diagnosis or recommend follow-up.
Following the surgery, the urologist intended to see the
woman for a 12-month follow-up review and arrange
surveillance imaging, but this did not occur. About two
years after the surgery, the woman was diagnosed with
advanced lung cancer and sadly died shortly
afterwards.
In their complaint to the Health and
Disability Commissioner, the woman’s family raised
concerns that inadequate radiology reporting and inadequate
follow-up after surgery resulted in a delayed diagnosis of
her lung cancer.
In her report Ms Cooper highlighted
the need for radiologists to follow current guidelines for
written radiology reports, including possible diagnoses if
anything appeared abnormal, and appropriate recommendations
to follow-up. She highlighted the importance of robust
processes for postoperative follow-up and surveillance after
surgery to remove cancer.
“I want to acknowledge the
distressing impact of these events on the woman and her
family. Given the advanced stage of her lung cancer at the
time of diagnosis and the devastatingly short timeframe
between diagnosis and death, it is understandable that her
family sought an independent review from HDC.”
Ms
Cooper found that the radiologist failed to report on the
findings of the woman’s CT scan adequately and failed to
make appropriate recommendations for follow-up.
“In my
view, in failing to report on the findings of the
[abnormality] in the right lung adequately and make
appropriate recommendation for follow-up, the radiologist
did not provide services to the woman with reasonable care
and skill, and therefore breached Right 4(1) of the Code of
Health and Disability Services Consumers’
Rights.”
Ms Cooper found that the urologist did not
have adequate processes in place to ensure that appropriate
follow-up review and surveillance imaging was arranged after
the woman’s kidney surgery.
She found timely
follow-up imaging was not arranged in accordance with
relevant guidelines (either at six months or one year
postoperatively). As a consequence an opportunity to
diagnose and treat her lung cancer at an earlier time was
missed.
“In my view the urologist failed to provide
services to the woman with reasonable skill and care and,
accordingly breached Right 4(1) of the Code,” said Ms
Cooper.
Ms Cooper recommended the radiologist arrange
for a clinical peer review of the standard of his radiology
reporting.
She recommended the urologist provide an
evaluative report on the effectiveness of the changes that
were implemented as a result of this case, and advise of any
further changes made or considered as a result of the
evaluation. He was also required to apologise in writing to
the family.
The full report of this case can be
viewed on HDC’s website – see HDC’s ‘ Latest
Decisions‘.
Names have been removed from the
report to protect privacy of the individual involved in this
case. We anticipate that the Commissioner will name DHBs and
public hospitals found in breach of the Code unless it would
not be in the public interest or would unfairly compromise
the privacy interests of an individual provider or a
consumer. HDC’s naming policy can be found on our website
here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
© Scoop Media
[ad_2]
Source link