Deputy Health and Disability Commissioner Rose Wall has detailed problems in the handling of multiple ultrasounds.
In the first case, signs of congenital pulmonary airway malformation were missed in a foetus, despite multiple ultrasounds. The condition was detected at 36 weeks by a different radiologist, delaying treatment that could have been carried out as early as 20 weeks.
The baby underwent surgery before and after being born by Caesarean, including the removal of their right lung.
Three of the four scans performed had "suboptimal images", failed to meet guidelines and often had incorrect labelling, the report said.
The radiologist did not recognise the cystic mass and failed to recommend the mother for tertiary referral at the time of the scan.
The second complaint involved a twin pregnancy where possible renal anomalies in one twin were overlooked during five scans.
Despite evidence of abnormalities as early as 20 weeks, necessary follow-up steps were not taken, the radiologist signed off reports without seeing all the images, and one twin died three days after birth.
Wall said these cases underscored the importance of maternity ultrasounds as vital tools for early detection of foetal issues.
"In each case, this resulted in missed opportunities to diagnose medical issues with the developing foetus at the earliest opportunity. This delay in diagnosis had a profound and lasting impact on the consumers concerned and their wider whānau," she said.
Both practitioners were referred to the Medical Council of New Zealand and the Medical Radiation Technologists Board.
The radiology service involved in the breach of the Code of Health and Disability Services Consumers' Rights had since introduced additional staff training and an audit of past scans.
Wall also made further recommendations for improving standards and accountability within the radiology service in question.
