An internal investigation has revealed an IT error was the cause of a year-long delay in a terminally ill man receiving test results from Hawke's Bay District Health Board.
Now, his grieving widow is filing a lawsuit against the health board, saying her partner could still be alive were it not for the error.
Toni Woods' partner Lindsay Collinson had a CT scan in July 2016 after falling ill on a romantic get-away in Paris.
A radiologist wrote a report saying there were enlarged nodes in his chest and neck but the couple were never told and nothing was done.
More than a year later Collinson was still unwell so went to a private cardiologist who found the report. He immediately ordered a new scan which showed his nodes had grown from 18mm to 27mm.
It also found metastasised cancer with a growth in his L5 vertebra which had fractured his spine and was causing his back pain.
Four months later Collinson was dead.
A internal investigation was launched by the board in May after questions from the Herald.
Findings of the investigation, released by Woods to the Herald this week, included:
• The scan was missed because the doctors could not access Collinson's results due to an IT error.
• The DHB had no system in place to track or record outstanding test results like Collinson's.
• A paper copy of Collinson's scan was never given to the clinician and the reason for that was unknown.
• Several clinicians attempted, on more than one occasion, to view the results but it came up as "pending".
• After finding the results were "pending" no further steps were taken despite recognising the results were significantly delayed.
A letter of apology detailing the mistakes made by the DHB was delivered to Woods in person by the DHB's patient safety and clinical compliance manager Kaye Lefferty.
"I was told I would find the letter very distressing and difficult to read. She said if I wanted to they could make a time and discuss the outcome with me," Woods said.
Instead, Woods has taken her case to a lawyer.
"If this happened to Lindsay then how many other people were affected by this glitch and unknowingly had scans that had never been followed up. It shouldn't happen and it's wrong."
The review stated: "Issues with the DHB's communication with affected patients and families had been identified prior to this event and a new process has since been established and implemented.
"This does not mitigate the distress caused to Mr Collinson and his family, or the clinical staff involved in the event."
But, a Hawkes Bay DHB spokeswoman told the Herald no other patients had been affected.
The spokeswoman said as a result of the concerns identified in Collinson's review, the board was working on their communication with patients and families regarding adverse events.
"Patients and families are now involved in the review process and we keep them informed as we progress the reviews."
The spokeswoman said the board had apologised to the family over the phone and had made several attempts to meet the family in person.
"We sincerely apologise for the distress the delayed diagnosis had on the family, and would welcome an opportunity to meet with them in person."
Woods said she believed that if the scan had been acted on straight away, her partner would have had a biopsy and they could have started treatment earlier.
"He could have been cured or at least he would still be alive now."
But the hospital spokeswoman said it was impossible to say if Collinson's life would have been prolonged if he had received treatment earlier.
"Mr Collinson had a number of other complex and serious medical conditions, as well as metastatic cancer."
Medical director of Cancer Society New Zealand and oncologist Dr Christopher Jackson told the Herald back in May he could not comment on the specific case but said the earlier the diagnosis the better.
"Obviously we want to get a diagnosis as early as possible so we can start treatment before it spreads.
"At the moment the Government is only reaching 15 per cent of people who have cancer in the very early stages so there are a lot of people out there with cancer who have not been diagnosed and this is definitely something we need to work on," Jackson said.
Woods has also laid a complaint with the Health and Disability Commission and an investigation is underway.
The Herald approached the commissioner in charge of the case for comment but due to privacy reasons a response could not be given.