Mistakes made by a sonographer and radiologist while assessing two pregnant women had tragic consequences. Photo / 123RF
Mistakes made by a sonographer and radiologist while assessing two pregnant women had tragic consequences. Photo / 123RF
A twin baby died three days after birth and another newborn needed to have a lung removed after mistakes made by the same sonographer and radiologist while assessing two pregnant women.
Through multiple ultrasounds, the pair failed to identify signs the baby who died was missing a kidney and bladder,despite there being evidence of possible anomalies in the twin from the 20-week scan onwards.
They also failed to identify signs of an airway malformation in the baby that had to have a lung removed once it was born.
The pair, who have expressed their sincerest regrets and apologies, have been referred by the Health and Disability Commissioner to the Medical Council of New Zealand and the Medical Radiation Technologists Board because of concerns about their competence.
Deputy Commissioner Rose Wall has found they also breached the Code of Health and Disability Services Consumers’ Rights for misdiagnoses of multiple ultrasound scans for the two pregnant women.
Deputy Health and Disability Commissioner Rose Wall.
Wall said the common element in each case was the failure of the sonographer and radiologist to maintain their respective standard of clinical practice during the performance of multiple ultrasound scans.
In each case, it resulted in missed opportunities to diagnose issues at the earliest opportunity.
“This delay in diagnosis had a profound and lasting impact on the consumers concerned and their wider whānau,” Wall said.
In the first complaint, the radiologist and sonographer failed to identify signs of congenital pulmonary airway malformation in the fetus through multiple ultrasound scans.
“Mrs A” became pregnant in 2021 and an early scan was reported as normal, with no abnormalities noted. A second ultrasound scan weeks later was “acoustically challenging” but no fetal abnormality was noted.
At a third scan, measurements obtained were normal, but because of the position of the fetus, not all required measurements could be obtained, and a follow-up anatomy ultrasound scan was scheduled.
The condition was identified by a different radiologist who found multiple cystic lesions had displaced and compressed the baby’s heart when the pregnancy was at 36 weeks.
The mother was referred urgently to the Maternal Fetal Medicine Clinic, where a specialist told her that if the condition had been picked up when it was first noticeable on the ultrasound scans at 20 weeks, the subsequent interventions would likely have been less invasive and more healthy lung tissue could have been saved.
After the late diagnosis, urgent interventions were initiated in utero but were not successful, which led to the baby being born by Caesarean section and requiring “multiple surgeries”, including the complete removal of his right lung.
The baby remained in the neonatal intensive care unit following surgery and was able to breathe on his own after a few days.
The sonographer and radiologist acknowledged they had both erred in missing the fetal abnormality in the anatomy scan.
Wall said a report into what happened found that three of the four scans performed by the sonographer had suboptimal images, did not adhere to the guidelines at the time, and on numerous occasions had incorrect labelling.
She found the radiologist had failed to recommend the pregnant woman for tertiary referral at the time of the anatomy scan.
“Mrs B” became pregnant in 2022 and had a routine scan with no abnormality found.
A third ultrasound scan was also normal and confirmed the pregnancy was twins. A growth scan at 24 weeks was also reported as normal.
A second growth scan weeks later showed one twin was on a smaller growth centile. However, there was no mention of the fetus being “significantly below normal range”, indicating that he might be a “stuck twin”, which is where there is a disparity in fluid volume and fetal size but no abnormality recorded.
Weeks later, Mrs B went into labour.
The maternity discharge papers recorded the pregnancy was “well” until delivery, with the twins born two minutes apart. The firstborn was taken to intensive care where the baby was found to be without a kidney and bladder and died three days later.
The sonographer, Mr C, said he “deeply regretted” his errors and the effect on the woman and her family.
“I again offer my sincerest apology,” he said in response to the complaint.
The radiologist, Dr D, said he also sincerely regretted not picking up the renal agenesis diagnosis in his review and report and apologised to the woman and her family for the stress they had suffered.
In the second complaint, Wall said the fetal anatomy imaging for both twins was incomplete, with images taken at the 12-week gestation period inadequate with suboptimal visualisation of the brain, extremities, kidneys and heart in both twins.
An expert adviser concluded that an obstetric review should have been recommended at 28 weeks’ gestation.
Wall concluded that the report findings emphasised the importance of scheduled maternity ultrasound scans as a principal opportunity to identify fetal developmental issues in utero.
The radiology service has since made changes, including additional training for staff and an audit of previous scans to prevent future occurrences.
Wall determined that the radiologist held overall responsibility for the reporting of each ultrasound scan and was required to provide the sonographer with feedback if the images did not meet the required quality or professional standard.
Wall made further recommendations for the radiographer and sonographer and the radiology service, including that Mr C enter into a mentoring relationship with a senior colleague for at least one year and that he reflect on the departure from the professional guidelines with respect to the images taken for the two women.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.
