Health – DHB response to “red flag” symptoms

Health and Disability Commissioner Anthony Hill today released a report finding a DHB in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to identify a woman’s “red flag” symptoms and for inadequacies in its system for requesting and cancelling CT scans.

The woman had a history of breast cancer, and had received extensive treatment including a mastectomy and radiation therapy. Many years later, the woman began to experience pain in her chest region, which worsened over the following months. The woman’s pain became severe and she experienced shortness of breath, so she visited the Emergency Department (ED) at the public hospital.

Staff at the hospital considered that her pain was the result of her recent breast reconstruction surgery. The woman was concerned that her pain represented a recurrence of her breast cancer and asked for a CT scan. A CT scan was ordered, but unfortunately it was cancelled by the Radiology Department when it did not hear back from the General Medicine team about whether the scan was required. The woman subsequently obtained a CT scan through her private insurance, which showed a recurrence of cancer in her breast and sternum.

Mr Hill considered that the woman had been “let down by various aspects of the care provided to her by numerous staff at [the] DHB.” He felt that staff had missed opportunities to identify and act upon clinical “red flag” symptoms and considered that the DHB’s system for requesting and cancelling CT scans was not sufficiently robust.

Mr Hill recommended that the DHB apologise to the woman in writing, update HDC on the implementation of a process to improve communication between the Radiology Department and referring clinicians and teams, and circulate the learnings from this experience. Mr Hill also recommended that training be provided to the staff who were involved in the woman’s care.

The full report for case 18HDC00630 is available on the HDC website.