A Taranaki radiology clinic has been censured after a woman was given pills to help her miscarry because a newly arrived overseas-trained radiologist mistakenly thought her baby was dead.
Health and Disability Commissioner Anthony Hill says the case highlights the need to assess, induct and oversee overseas-trained doctors, who make up 42 per cent of the country's doctors.
He found that Fulford Radiology Services Ltd was at fault for employing a radiologist from overseas who had virtually no experience of obstetric scanning, and giving him no training before he started work in its clinic.
The radiologist saw the results of the woman's scan on his second day in the job, which was his first day of clinical work in New Zealand.
The scan found no fetal heartbeat and led to the woman being given misoprostol tablets to assist with what was believed to have been a natural miscarriage.
However the woman found out seven or eight weeks later that the baby was still alive 17 weeks after conception.
She had originally wanted an abortion, and had the baby aborted six days after she found out that it was still alive.
Hill said: "This case is a salutary reminder of the need to ensure that the assessment, induction and oversight of new staff occur professionally and appropriately.
"New Zealand has a high proportion of internationally trained doctors (42 per cent). An assessment was made that ought not to have been, and, while the radiologist should have conferred with readily accessible colleagues, the employing authority needs to ensure that expectations and protocols - the way we do things - are made clear."
At the time, in 2015, Fulford Radiology was owned half by the Taranaki District Health Board and half by Taranaki Radiologists Ltd, a privately owned company whose directors were then and still are its operations director Dr Alina Leigh and principal radiologists Dr Maren Krueger and Dr Dana Tipene-Hook.
The district health board took over full ownership of Fulford Radiology in February 2016.
Board chief operations manager Gillian Campbell said both the board and the company "extend our sincere apologies to the patient and her family".
"The quality of care we provide is extremely important to our DHB and we are sorry for the upset and stress it has caused," she said.
Hill found that the woman originally went to her general practitioner seeking an abortion. She was referred to the Family Planning Association, which referred her to Fulford Radiology for a scan to determine the age of her fetus.
The sonographer who conducted the scan had also started working at the company only the day before on a fixed-term contract and was given virtually no training in scanning protocols.
"On her first day of work, the roster indicates she had a short 30-minute introduction session with another sonographer before commencing scanning," Hill was told.
"She said that on her first day at FRSL she 'had an entire day of patients to scan, which was about 15 in a day'. [She] stated that, particularly in the first few days, she felt she was under 'such time constraints' that she did not get her breaks and 'barely had time to have her lunch'."
After the scan did not find a fetal heartbeat, she "stated that she did consider performing a transvaginal scan, but her colleague told her that she had used the time period allotted for [the patient]".
Hill found that the sonographer "should have offered the woman a transvaginal scan" to make sure the baby was dead.
The scan was then reviewed by the overseas-trained radiologist, also on his second day in the job.
He told Hill: "My experience of obstetric scanning was limited mainly to first-trimester obstetric emergencies such as ectopic pregnancy detection because the practice [overseas] is such that other obstetric scanning is done in obstetric departments rather than in radiology."
He said that "based on his previous radiologist experience overseas, he 'incorrectly assumed that an obstetrician would decide if a transvaginal scan was necessary'."
With no fetal heartbeat detected, the woman was referred to a miscarriage clinic and was given misoprostol tablets to assist the miscarriage.
The error was discovered when the woman still had not had a menstrual cycle seven or eight weeks later and had another pregnancy test.
Campbell said the Taranaki District Health Board put the company under "a new management structure" in January 2016.
"The Taranaki community can be reassured we have learnt from this case," she said.
"As a result, Fulford has revised its first trimester obstetric (ultrasound) protocol further to require a scan diagnosis and a repeat scan in seven to 10 days to confirm if there is no heartbeat prior to 12 weeks.
"The DHB's human resource policies and protocols relating to recruitment, induction and orientation have been adopted by Fulford Radiology and a comprehensive orientation plan and staffing model has been introduced since this event.
"The purpose of the Health and Disability Commissioner process is independent. It is not about naming and blaming individuals but rather a process we can all learn from. The HDC has not released any names of others involved and we are abiding by that decision."