Radiologist Breaches Code For Poor Reporting Of Woman’s CT Scan 20HDC02040

A radiologist has breached the Code of Health and
Disability Services Consumers’ Rights (the Code) for poor
reporting of a CT scan, which may have delayed a bowel
cancer diagnosis for a woman who, sadly, died of a blood
infection from a bowel obstruction.

In a report
released today, the Deputy Health and Disability
Commissioner Carolyn Cooper said a radiologist breached
Right 4(1) of the Code – Tautikanga, failure to provide an
appropriate standard of care.

The woman had been
extremely ill and had a noticeable abdominal mass. An
abdominal and pelvic CT scan request form noted significant
clinical concerns and a possible malignancy.

The
radiologist’s report on the subsequent CT scan noted two
minor issues but ‘no obvious malignancy’. The
radiologist recommended an ultrasound follow up in three
months and, the woman was advised by another doctor that her
CT scan had not shown any obvious issues.

Several
weeks later, the woman was readmitted to Whangārei Hospital
severely ill. At this point, the radiologist re-reviewed her
abdominal and pelvic CT scan and picked up an abnormality,
which was not noted in the initial review. The radiologist
updated the CT scan report with an addendum, which reported
this abnormality and the need for further assessment. The
radiologist did not document whether communication of the
addendum to the CT requestor had occurred.

Two days
later, another doctor noted the addendum. A further medical
review was completed that day, and an MRI scan discovered a
cancerous mass causing a bowel obstruction.

Sadly, the
woman died a few weeks later. The Coroner found she had died
of septicaemia due to a perforated bowel which had become
obstructed by a tumour.

Deputy Commissioner, Ms
Carolyn Cooper found the radiologist breached the Code for
the inadequate reporting of the CT report, including the
failure to mention several important anatomical structures
and whether these structures appeared normal within the
report.

“I consider that the CT report was inadequate
as it did not mention the gastrointestinal tract, the
retroperitoneal structures, or the pelvic organs, and
whether or not these appeared normal.”

Ms Cooper made
an adverse comment about Health NZ Te Tai Tokerau. “I am
critical of the alert system and the process that was in
place for documentation of addendums. Clear documentation of
when and how the addendum was conveyed to the relevant
parties could have prevented confusion in Mrs A’s care and
the subsequent delay caused by the confusion.”

Ms
Cooper has made several recommendations, which are outlined
in detail in the report, and include that Health NZ provide
a formal apology to the woman’s
whānau.

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