Failures In Care Of Woman Later Diagnosed With Liver Cancer

Health and Disability Commissioner Morag McDowell today released a report finding a radiology service and radiologist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to a woman later diagnosed with liver cancer.

The report discusses the care provided to the woman, aged in her fifties at the time, prior to her diagnosis of liver cancer and, in particular, errors that occurred during a CT scan of her abdomen and pelvis.

"The radiologist should have reported that the liver lesions identified on the woman’s CT scan were difficult to characterise, and therefore he should have offered a differential diagnosis and recommended further imaging," Ms McDowell said.

"His failure to do so contributed to unacceptable delays in the diagnosis of the woman’s liver cancer," she said.

The Commissioner found that the radiologist failed to provide services to the woman with reasonable care and skill. She noted that when the nature of the tumours was confirmed, it was too late to offer the first line of treatment, which would have been surgical removal.

"However, it is not possible to determine with any degree of certainty whether such surgical removal would have been curative," Ms McDowell said.

The Commissioner recommended the radiology service share the report, including the expert advisor’s advice, with all its radiology staff across the radiology service branches in New Zealand, and review its processes to determine what steps it could put in place to prevent or minimise interruptions for radiologists who are undertaking complex analyses.

She also recommended that, in addition to strongly encouraging radiologists to undertake a double reading of complex or difficult cases, it consider whether any processes and/or guidelines could be developed to ensure that this occurs with consistency.

The full report on case 20HDC00356 is available on the HDC website.

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