Patient dies after 'fatigued' Waikato ED doctor misses lung lesion

Source: 1News

An Emergency Department doctor and Waikato DHB have been found in breach of a patient’s rights after she died of lung cancer following a misdiagnosis by a "fatigued" doctor.

Radiologist showing tomography scan of a patient's lungs over of CT machine.

An abnormal mass was found on a woman in her 60s who visited a Waikato Emergency Department (ED) in 2017 but her radiology results were not picked up for another three years.

The incident was detailed in a report released on Monday by the Health and Disability Commissioner Morag McDowell.

The HDC found there was an 11-day stall between the patient’s chest X-ray being taken on March 11 and it being sent to the radiology service after she had presented at the ED with stomach pain and nausea.

The doctor who ordered the X-ray reviewed the results but missed the radiologist’s findings of a mass-like lesion on the woman’s lung.

"I believe fatigue is likely to have been the reason why I overlooked the comments about the mass and recommendation by the radiologist and I deeply regret this," the doctor responded.

The woman’s GP practice received the report but with no instructions from the DHB about its findings.

It was not until the woman went back to ED in January 2020 with a suspected stroke that a consultant reviewed her 2017 chest X-ray report and another X-ray and a CT scan were ordered.

A biopsy in February found she had terminal lung cancer – and has since died from the illness.

McDowell was critical that the woman’s GP practice did not follow its own policies, and safety-netting intended to prevent abnormal test results from being missed was not engaged, and another opportunity to follow up the abnormal X-ray result was missed.

She found that the DHB’s failure to ensure that radiology reporting was completed in an acceptable timeframe amounted to a breach of Right 4(1) of the Code.

However, McDowell found the primary responsibility for taking further action on the radiology report lay with the ED clinician.

"In overlooking the reporting radiologist’s comment about the significant abnormal mass and, consequently, failing to take any follow-up action, the ED clinician failed to provide services to the woman with reasonable care and skill, and breached Right 4(1) of the Code."

The Commissioner recommended multiple audits be done by the DHB in relation to its radiology reporting and tasked the ED doctor with auditing their own radiology reports. The doctor has apologised to the woman’s family.

The Commissioner also recommended that the medical centre conduct an audit of test results ordered by third parties.