District Health Board Fails To Facilitate Careful, Thorough, And Timely Reporting Of Scans Before Surgery

Deputy Health and Disability Commissioner Deborah James today released a report finding a District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to have in place guidelines and policies to facilitate careful, thorough, and timely reporting of scans and X-rays before surgery.

A man in his eighties with liver cancer was reviewed by a specialist surgeon at the DHB to confirm his suitability for a liver resection. Following an anaesthetic assessment, the man was placed on the waiting list for surgery.

After a month’s wait the man was added to the specialist’s list for surgery in five days’ time. The specialist noted that the man had not had any imaging (scans or X-rays) for several months, so he referred the man for an urgent CT scan with his local DHB.

Due to errors in the manual processing of the referral at the local DHB, an urgent tag was not added. Machine failures also delayed the man’s CT scan, and it was done only two days prior to surgery.

The scan was not reviewed by a radiologist at the local DHB, nor was it reviewed by a radiologist when it was emailed to the operating DHB.

The surgeon reviewed the images on the morning of the man’s scheduled surgery and concluded that a liver resection was still feasible. The surgeon did not identify from the scan that the man had small lung nodules, indicating that the cancer had spread.

Although the surgery went well, a follow-up scan reviewed by the radiologist at the man’s local DHB identified the lung nodules. The man was diagnosed with prostate and lung cancer, as it had spread. Sadly, the man passed away.

Deputy Commissioner Deborah James considered that the operating DHB failed to identify the man’s spreading cancer, due to a series of system failures, including:

- not identifying the need for preoperative scans until five days before the surgery;

- the lack of a system in place to ensure that the CT scan was reported on by a radiologist prior to surgery; and

- an absence of guidelines, protocols, or policies to guide clinicians who receive images that have not been reported on.

Ms James also criticised the local DHB for carrying out a CT scan and forwarding the images to the operating DHB without a report. In an attempt to speed up the man’s referral, the request was not tagged as urgent, and therefore was reported as a routine outpatient scan. This resulted in the scan not being read in time, and contributed to the failure to identify the man’s spreading cancer before surgery.

Ms James recommended that the operating DHB create and implement a policy to ensure that imaging taken prior to cancer surgery is reported on or reviewed in conjunction with a radiologist, and documented prior to surgery. She also recommended that a guide be created to outline which preoperative investigations should be considered before liver cancer surgery, and when. Ms James recommended that a safeguard also be created to ensure that appropriate actions occur in a timely manner before surgery.

The man’s local DHB indicated that it had started a text messaging system in the Radiology Department for communication about urgent reports, and Ms James recommended that the DHB report on whether this is an effective initiative.

Ms James recommended that both DHBs provide an apology to the man’s family.

The full report for case 19HDC01944 is now available on the HDC website.

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