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Woman's Tumour Undetected By Radiologist And DHB Staff

Deputy Health and Disability Commissioner Deborah James today released a report finding a radiologist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to identify a pancreatic tumour on a woman’s CT scan.

The woman, in her seventies, visited her GP with abdominal pain, lack of appetite and weight loss. She was referred to a private general surgeon who referred her for a CT scan to investigate her symptoms after a gastroscopy and a colonoscopy showed no abnormalities.

The radiologist reported that the CT presented "unremarkable findings". When the woman’s symptoms continued she was admitted to the public hospital. Her CT scan was imported into the DHB and marked for "clinical review." However, the scan was not reviewed during her stay in hospital.

After discharge from hospital, the woman’s symptoms continued and she was reviewed by a consultant physician and gastroenterologist. They reviewed the woman’s earlier CT scan and noted it showed a mass suspicious of pancreatic cancer.

The woman was diagnosed with advanced pancreatic cancer, and sadly died.

The Deputy Commissioner considered that the radiologist did not provide the woman with reasonable care and skill.

"While acknowledging that perception errors will occur, it’s my opinion that the woman’s pancreatic mass and secondary signs should have been picked up by the radiologist," said Deborah James.

She considered that aspects of care provided by the DHB could have been improved, and should have included undertaking a radiology review of the woman’s CT scan.

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"I acknowledge that the woman’s scan having been reported to the DHB as normal, may have influenced the clinician’s decision-making during her admission, particularly in regard to undertaking further investigations," said Deborah James.

She recommended that the radiologist implement a "checklist" structured reporting style to provide a cue for each abdominal organ to be evaluated carefully, and familiarise himself with the various radiological manifestations of pancreatic cancer.

She also recommended the radiologist provide a written apology to the woman’s family.

The full report of case 19HDC01960 is now available on the HDC website.

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