A radiologist who made "serious errors" and missed the signs of liver cancer which killed a Southland Hospital patient could face legal action.
The same radiologist also misdiagnosed another Southland patient, who was subsequently found to have terminal liver and pancreatic cancer.
Reports released by health and disability commissioner Morag McDowell yesterday detailed the two cases, referring to the consultant radiologist as Dr B.
The incorrect diagnoses resulted in "devastating outcomes" in both cases, the reports said.
Dr B still worked in the private and public sectors — although not for the Southern District Health Board, now Te Whatu Ora Health New Zealand — and Ms McDowell said there was a public interest in accountability for his major shortcomings of care.
"I believe it is appropriate to refer Dr B to the director of proceedings to consider whether further action is necessary to hold Dr B to account for his serious breaches."
The first report concerned a man in his 70s who underwent a CT scan in January 2018 at Southland Hospital to investigate a mass in his liver.
Dr B interpreted the scan and concluded the mass was benign.
However, after a follow-up CT scan in January 2019, the man was diagnosed with cancer that had spread to other parts of his body. He subsequently died from his illness.
Ms McDowell was critical that Dr B did not correct an incomplete CT protocol when he became aware the imaging was inadequate, which ultimately resulted in substandard interpretation of the scan.
Dr B was quoted in the report acknowledging he should have repeated the scan or taken other steps.
The report said Dr B had accepted his errors, but submitted that referral to the director of proceedings was unnecessary because of the audits of his readings, the recertification programme imposed, and changes he had made to his practice.
He had also put forward mitigating factors.
"In particular, he asserted that at the time, his workload was high due to understaffing and under-resourcing at SDHB."
Dr B noted that SDHB’s investigation showed he had reported more scans than other radiologists from January to May 2018.
He also said he was suffering from severe pain at the time while he awaited surgery, and this was affecting his daily work, sleep and performance
The second report investigated the care Dr B provided after a man came to the Southland Hospital emergency department with stomach pain in 2017.
Following an MRI in 2018, Dr B reported a benign liver lesion and stated that no further follow up was required.
In 2019, the man was admitted to hospital with abdominal pain.
"A follow-up ultrasound identified that the original liver lesion had increased in size substantially," the report said.
"An internal multidisciplinary radiology meeting found that the MRI read by the radiologist in 2018 was consistent with liver cancer."
The patient was subsequently diagnosed with terminal liver and pancreatic cancer.
Ms McDowell found Dr B breached the code of health and disability services consumer’s rights.
In the first report Ms McDowell found him in breach for failing to provide services with reasonable care and skill.
She determined that the SDHB did not breach the code in this case, although she identified several areas for improvement.
In the second report she found Dr B in breach for misdiagnosing the man’s liver lesion on an MRI as benign when in fact it was suspicious of liver cancer.
This error "fell significantly below the standard of care reasonably to be expected of a consultant radiologist".
"Clinical evidence provided to my investigation concluded that the misdiagnosis by Dr B resulted in [the patient’s] treatment of cancer changing from being potentially curative to becoming palliative."
The second report also found the SDHB failed to respond appropriately in the context of being on notice about Dr B’s earlier misread in another case.
The SDHB had breached the code for an unacceptable delay of about nine months from becoming aware of the mistake to beginning an internal investigation into the radiologist’s misread.
Ms McDowell acknowledged radiology reporting was complex and there was a risk of human error, but this was not determinative in assessing whether the standard of care had been met in a particular case.
