Doctor missed lung cancer that killed man after mistaking patient’s name for another

A mass on the patient's lung grew from 15mm to 45mm within three months but it could have been treated when detected on a chest X-ray at 19mm if not for a mix-up in patients by a doctor. Photo / 123rf

A man’s lung cancer was missed when a hospital doctor muddled him up with another patient and failed to check a radiologist’s X-ray report detecting the mass and recommending action.

The man died the next year but not before complaining that his delayed diagnosis and treatment by Te Whatu Ora Waitaha Canterbury left him angry at staff who made decisions about his care without consulting him.

Both the doctor and Te Whatu Ora have been found in breach of the Code of Health and Disability Services Consumers’ Rights in a decision released by the Health and Disability Commissioner [HDC] today.

The man, identified in the decision as Mr A, was in his 80s and had diabetes, heart disease, high blood pressure, and elevated cholesterol when he presented to a public hospital emergency department several times in early to mid-2019 with chest pain.

On August 6 and 10 he was admitted to hospital for chest pain and no abnormalities were noted from chest X-rays though the August 6 X-ray has since been reviewed and a 15-millimetre density was seen.

Mr A returned to the ED on August 29 with pain and weakness and had another chest X-ray. A radiology report the next day noted a 19mm nodule and recommended a CT scan.

However, he was discharged before the report was available and a general medicine physician, Dr B, accepted the report on September 2 and took no further action.

He later told the HDC this was because he had another patient with a similar name whose radiology report showed almost identical findings to Mr A’s, and this led him to mistakenly believe both reports were the other patient’s.

Because of that he marked Mr A’s report as accepted in the mistaken belief he was accepting the other patient’s results.

It meant that he did not update Mr A’s discharge summary which meant neither Mr A, nor his GP were informed of the X-ray results.

On October 6 Mr A returned again to hospital, unable to move and in pain, and underwent another chest X-ray.

The radiology report dated the same day notes a 35mm “mass-like density” that had increased in size from previous X-rays and queried whether the earlier recommended CT scan had been done.

The next day Mr A was told by respiratory registrar Dr D that further investigations would be required to confirm suspected lung cancer.

But no one told Mr A the mass had been found more than four weeks earlier.

Mr A told HDC that he was “deeply distressed” to hear he had lung cancer.

He said he was angry and disappointed at the lack of respect shown by the medical staff who made decisions about his treatment without consulting him.

He felt they needed to “understand the consequences of their actions, and he was extremely concerned that this might happen to someone else”.

However, the problems with Mr A’s care did not end there after the referral for a fine needle aspiration biopsy was also delayed.

Deputy Health and Disability Commissioner Deborah James was critical of Dr B for failing to take further action on radiologist's report which meant opportunities were missed to diagnose and treat the cancer earlier. Photo / Supplied

The October 7 referral request had a target date of less than two weeks but it didn’t happen until November 5 because of strike action by medical imaging technicians which had an impact on outpatient appointment scheduling.

Mr A was offered radiation or palliative care and he chose radiation, but died in 2020.

Medical oncologist Dr Orlaith Heron gave expert advice that although there was a delay in diagnosis, it most likely did not affect the outcome for Mr A as his cancer was rapidly growing, already large, and likely at an advanced stage.

However, she said the failure by Dr B to action the radiology report on August 30 and the delay in advising Mr A of that failure once it was discovered was a departure from the standard of care required and Deputy Commissioner Deborah James agreed.

“The result of Dr B’s failure to take any further action on the radiologist’s report was very serious,” James said.

“The CT scan recommended in the report was not carried out, and by the time the mass was identified a month later, it had increased in size substantially. Because the discharge summary was not updated with the result, Mr A and his GP were also deprived of the opportunity to take action on it.”

She found the physician in breach of Right 4(1) of the Code, the right to have services provided with reasonable care and skill.

James noted a similar case was reported by the HDC in March this year where a senior emergency medicine clinician also breached the Code for failure to take action on a radiologist’s report of a mass in a patient’s lung, and accepting the report on a hospital computer system without ensuring any further action was taken.

In Mr A’s case, James also said that despite several different clinicians in two different departments being aware of the failure to action the radiologist’s report, no clinician took responsibility for ensuring that Mr A was informed of this error at the earliest opportunity.

“Systemic issues at Canterbury District Health Board constituted a failure to ensure that the man had all the information that a reasonable consumer in his circumstances would expect to receive,” James said.

She found Te Whatu Ora Canterbury in breach of Right 6(1) of the Code, the right of the consumer to be fully informed.

James recommended the physician, who wrote an apology to the man’s family, have 50 radiology reports he had responsibility for audited, to identify whether significant abnormal findings were being actioned.

She made a number of recommendations to Te Whatu Ora including that it also formally apologise to the family.

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.