Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Health and Disability Commissioner Anthony Hill today released a report finding Hawke’s Bay District Health Board (HBDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for multiple systems failures.
A man underwent a CT scan that revealed several concerning findings including possible malignancy. However, an IT issue meant that the radiologist’s scan report was not made available on the Electronic Clinical Application system used by clinicians, and clinicians were also not aware that they could view the report on the Radiology Information System.
The man’s scan report was first seen by a clinician over a year later, and he was diagnosed with metastatic adenocarcinoma (cancer) shortly afterwards. Sadly, the man passed away.
Mr Hill was critical that HBDHB’s multiple systems failures meant that the man’s treating clinicians were unable to view his CT scan report for over a year, which delayed his treatment. He considered it was unacceptable for investigation reports to fail to reach the ordering clinician.
“[HBDHB] has a responsibility to ensure that there are appropriate systems in place so that clinicians receive important information relating to patient investigation results.”
Mr Hill noted that HBDHB had “identified and rectified the IT error that occurred in this case, and that its new Clinical Portal is expected to improve access to radiology reports.”
Mr Hill recommended that HBDHB provide a written apology to the man’s wife, which has now been done. Mr Hill also recommended that it update HDC on the implementation and effectiveness of its new Clinical Portal and conduct a review of waiting times to access its Cardiology and Rheumatology clinics.
The full report for case 18HDC00858 is available on the HDC website.