Source: Health and Disability Commissioner
Following complaints of leg pain, a man underwent a Magnetic Resonance Angiography (MRA) at Whangarei Hospital. The MRA showed a significant incidental finding of a tumour on the man’s right kidney, however, there was a four-month delay before the man was informed of the finding, which came in the form of an unexpected letter from the urology clinic. Following his diagnosis, the man required a nephrectomy (removal of the kidney) and commenced treatment for metastatic cancer.
Dr Caldwell said, “several contributing factors led to the unacceptable delay in this person being advised of the results”. She found Health NZ breached the Code for not providing an appropriate standard of care and for failing to provide full information.
The breaches resulted from the MRA scan results not being communicated to the man in a timely manner and both the urology referral and booking of a renal CT scan were overlooked. Dr Caldwell said she was concerned about the oversight of tasks that arise from the multidisciplinary team meeting (MDM) discussions. “While the role of the multidisciplinary team is to determine the most suitable treatment plan for patients, it also needs robust processes to oversee that the plan has been followed through, and people are assigned the tasks to be responsible for actioning” she said.
The HDC also found there was a lack of agreement with the radiology service for the communication of test results. Health NZ was alerted to the incidental finding by email. However, Dr Caldwell said the renal mass in the MRA was a significant incidental finding and it is well understood that email communications, on their own, are not a reliable way to communicate urgent findings.
Dr Caldwell said what while some of the deficiencies may appear minor individually, cumulatively they led to a poor standard of overall care.
Since the events, Health NZ and the radiology service have made several changes. Dr Caldwell outlined further recommendations in her report, including that Health NZ provide HDC with an update on the recommendations for improvements made in their adverse event report.
