The HDC’s decision, released yesterday, showed although the patient was examined several times between 2017 and 2020, ‘‘over a series of investigations, the lesion in the right upper lobe was either not seen . . . or deemed to be stable and benign . . and the respiratory physician dealing with the referral was acting on the reports and made a decision not to pursue any further follow up imaging’’.
‘‘On the CT scan of May 2017, there was an unexpected 20mm nodule in the right upper lobe suspicious of malignancy, not followed up at this point or at future interactions until 2022.’’
By the time they reached a correct diagnosis, the patient, referred to in the decision as ‘‘Mr A’’, had stage four lung cancer which had spread to the upper spine.
The issue began in May 2017 when Mr A, a non-smoker, went to hospital complaining of ‘‘chest pains’’.
The commissioner said Health New Zealand Te Whatu Ora Southern had a responsibility to provide Mr A with an appropriate standard of care between 2017 and 2022.
‘‘In my view, there were several missed opportunities by staff at Southland Hospital to identify Mr A’s malignancy and escalate his care appropriately.’’
The commissioner outlined a litany of events and management flaws that led to the seriously delayed diagnosis.
These included the fact there specialist radiology at the hospital was understaffed, meaning that staff were working ‘‘in an environment often with a greater number of hours and with distraction’’.
‘‘There is no radiology registrar on the Southland site to support the radiologist workload — the senior medical officer supervising the modality will be reporting, acting as registrar (taking acute calls) and protocolling examinations all at the same time.’’
Many reports were also reviewed in an noisy environment where distractions could not be avoided; while ‘‘the opportunity for peer review is challenging with lack of resourcing’’.
All these factors led to critical mistakes, the commissioner said.
Mr A enlisted the help of a lawyer with his situation, who assisted with the initial response from the HDC and the ACC assesment.
His lawyer was scathing.
‘‘We note within the provisional report some of the excuses offered by [Health NZ Southern] in respect of the environment, work pressure, working conditions etc that the radiologists had to work in.
‘‘With respect, that is not the patient’s fault.
‘‘We note that multiple parties from different working environments, all of whom are deemed to be professional clinicians, failed [Mr A] significantly and repeatedly.’’
Mr A wondered whether his situation would have been different if the doctor had been ‘‘competent’’ back in 2017, his lawyer said.
‘‘[Mr A] is now dealing with multiple metastases, liver and venous compromise, brain bleeds and lesions now becoming evident in his spine and other bones,’’ the lawyer said.
The commissioner made a slew of recommendations for Health NZ Southern and Southland Hospital.
These include reviewing alternative options for managing the day-to-day radiology processes to reduce distraction, reconfiguring the working environment to allow the undertaking the reading of images to have quiet protected time, and regular peer reviews and staff re-training.
HNZ Southern should also ‘‘consider establishing a business case for a radiology registrar in Southland Hospital’’, while it had to provide a written apology to Mr A for the failings identified.
An anonymous version of the commissioner’s report should also be used to conduct a training session for the radiology and respiratory departments.
