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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

The Health and Disability Commissioner today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failings in the care provided to a man following the discovery of a lung lesion.
The man, aged in his fifties, was taken by ambulance to the Emergency Department (ED) at the public hospital following an accident. A CT scan revealed a right upper lung lesion, along with multiple spinal compression fractures.
During the man’s six-day stay in hospital, his care focused on the acute spinal injuries, and communication of the incidental finding of a lung lesion did not occur as he was transferred between teams. The man’s family was informed of the lesion verbally, but it was not documented on his ED medical record or his discharge summary, and no documentation of the issue was provided to either the man or his family. The man’s general practitioner was provided with a copy of the ED medical record and the discharge summary, but was not notified of the lung lesion.
Nearly five months later, the man re-presented to the DHB with right-sided facial droop, right arm weakness, and slurred speech. CT scans revealed that a primary lesion in his right lung had metastasised to his brain. The man was diagnosed with metastasised lung cancer, and sadly passed away.
Former Commissioner Anthony Hill found that no single doctor took responsibility for the incidental finding of the lung lesion. The finding was not recorded in the man’s discharge summary or communicated to his GP. The Commissioner concluded that this denied the man the opportunity for earlier diagnosis and intervention for his lung cancer.
“I am mindful that the follow-up of incidental findings is a challenging issue being faced worldwide,” said Mr Hill. “However, I consider that this case has highlighted areas for learning and improving communications in regard to incidental findings in a clinical setting. There were a number of missed opportunities to take action… DHBs should have in place appropriate systems to facilitate the continuity of care for their patients as they move through the health system.”
Mr Hill recommended that the DHB provide HDC with a copy of its new mandatory departmental policy on incidental findings; create a package of educational material on the standards of practice expected in relation to incidental findings and specific systems to help reduce the risk of incidental findings not being followed up; and provide HDC with an update on changes made since the event.
He also recommended that the DHB use an anonymised version of the report for training staff, undertake intermittent audits of the adequacy and observance of DHB policies relating to incidental findings that require action, and provide a written apology to the man’s family.
The full report for case 19HDC00851 is available on the HDC website.

MIL OSI