Health News – Providers must acknowledge and respond to increasing demands on service in order to maintain safe practice

Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found a failure by a radiologist to identify a lung lesion on a woman’s CT scan, and failure by Hawke’s Bay District Health Board (HBDHB), now Te Whatu Ora – Te Matau a Māui Hawke’s Bay, to maintain standards by managing increasing demands on its service were in breach of the Code of Health and Disability Services Consumers’ Rights (the Code).

A woman aged in her sixties at the time of the events was referred to HBDHB Radiology for a screening colonoscopy due to a strong family history of bowel cancer. The woman underwent an abdominal CT scan in November 2016 that included images of her lung bases in November 2016. A lesion was visible in the right lower lung, but this was not reported by the radiologist, and further investigation was not requested.

The lesion was not clearly identifiable in later x-ray images taken in 2016, 2017, and 2018, and was not identified until a CT scan of her abdomen and pelvis in February 2020. Sadly following further investigation, the woman was diagnosed with lung cancer.

In her decision, Dr Caldwell acknowledged that “radiology reporting is a complex perceptual and cognitive task, and some degree of human error is unavoidable, noting working conditions may increase the risk of error”.

“However, as stated by this Office previously, acceptance that errors of perception occur in a small but persistent number of radiology interpretations is not determinative in assessing whether the standard of care has been met in a particular case.

“The woman’s lung lesion was visible on the CT scan of 4 November 2016, and should have been reported. Taking into account independent advice, I consider the failure by the radiologist to report this resulted in a missed opportunity for earlier diagnosis and treatment.

“I have taken into account HBDHB’s acknowledgement that the Radiology Department was under-resourced in 2016, but the consensus of opinion is the lesion was visible on the CT scan in 2016 and should have been reported.

“The lesion was a significant finding, and the woman was specifically being screened for cancer in light of her family history. I consider the radiologist’s scan report did not meet an adequate standard for care,” says Dr Caldwell.

As a healthcare provider, HBDHB is responsible for providing services in accordance with the Code, and as such, required to provide a safe and appropriate workplace environment, and ensure adequate processes to manage clinician workloads.

Dr Caldwell considered that “the radiologist’s error indicates broader systems and organisational issues at HBDHB”.

“HBDHB has an obligation to provide services to consumers with reasonable care and skill, and ensure employees have the conditions necessary to perform their work to an appropriate standard.

“I consider the HBDHB’s response to increasing radiology workloads was insufficient to support the team to maintain standards in the face of increasing demands on the service,” says Dr Caldwell.

Dr Caldwell recommended that HBDHB and the radiologist provide a written apology to the woman and her family, and that the radiologist implement a checklist structured reporting style and familiarise himself with the various radiological manifestations of lung cancer.

She also recommended that HBDHB ensure staff are aware of the formal processes available for clinicians to raise concerns about their working environment and the process for concerns to be acknowledged and addressed by the organisation; undertake an updated audit of 30 randomly selected abdominal CT scans to confirm improvement in reporting of lung bases; and consider improvements to the reporting process to prevent similar errors occurring in future.