A woman was moments away from having a procedure to remove a miscarried baby when she requested a final scan which showed her baby was alive and growing.
Health and Disability Commissioner Anthony Hill today released a report finding a sonographer and a radiologist were in breach of the Code of Health and Disability Services Consumers' Rights for services provided to the woman.
The woman had gone for a transabdominal scan after her GP raised concerns about her pregnancy during her first trimester and the sonographer found no observable yolk sac, and no fetal pole or heartbeat.
He did not offer her a transvaginal scan but noted he did not believe the pregnancy was viable.
The woman and her family met with an obstetrician, gynaecologist and a midwife after the scan where she was told she had miscarried and presented with her options.
She chose to wait a few days to see if the early pregnancy tissue would be expelled without intervention and come back for a dilation and curettage (D&C) if that did not happen.
Five days later she returned for the D&C but requested a final ultrasound for her peace of mind before the procedure to remove the contents of the uterus.
The doctor said that because her β-hCG levels had risen appropriately for an ongoing pregnancy and the woman said she still felt pregnant, he considered that the repeat scan was appropriate.
The ultrasound found a viable embryo of 17.6mm so the procedure was not performed and her pregnancy continued.
The woman told the Health and Disability Commissioner she was "very distressed" when she thought she had miscarried and in the days before her D&C was scheduled she drank alcohol, ate unsafe food and took medications which were potentially harmful to the baby.
Hill found it was incorrect for the sonographer to conclude the pregnancy was not viable based on the one scan and was critical of him for not offering the transvaginal scan.
He recommended the Medical Radiation Technologists Board consider a review of the sonographer's competency. He also recommended the sonographer apologise, arrange an audit of his first-trimester viability scans and report on learnings from a professional development programme.
Hill was also critical of the radiologist responsible for interpreting the images for failing to report no transvaginal scan had been done and that further investigation was needed to determine the viability of the pregnancy.
He recommended the radiologist also carry out an audit and that the district health board use this situation as a case study to highlight the importance of clear communication between sonographers and radiologists.
The district health board was also required to update the sonographer worksheet to show it was a provisional report pending radiologist review among other things.