Hospital safety: 12-year-old’s near miss after radiology report showing liver bleed went missing

Dr Bryan Wolf, a consultant radiologist in Hawke's Bay, who has been pushing Te Whatu Ora - Health New Zealand to be more open about safety risks arising from defective information systems.

The Herald has obtained a report by a whistleblower doctor alleging a child could have died because of an IT flaw at Hawke’s Bay Hospital. ALEX SPENCE reports that it sheds light on one of the biggest challenges faced by Te Whatu Ora-Health New Zealand in restructuring the national health system.

A 12-year-old girl who suffered a serious liver injury in a car accident could have died because an urgent radiology report did not show up in a hospital’s electronic records system, according to documents obtained by the Herald.

The alleged near-miss was one of several incidents that Dr Bryan Wolf, a senior doctor at Hawke’s Bay Hospital’s radiology department, claimed were evidence of deep-rooted technical and cultural problems that endangered staff and patients at the hospital until last year.

Wolf submitted at least five detailed reports to senior executives at Te Whatu Ora-Health New Zealand which highlight one of the major challenges thrown up by the biggest public restructuring in New Zealand history. In merging 20 regional health authorities, Te Whatu Ora has inherited thousands of IT systems that are often outdated and severely flawed.

In one report, which has not been made public, Wolf claimed that an unnamed child was taken to Hawke’s Bay Hospital after a vehicle collision in November 2022. The 12-year-old was sent by emergency department doctors for a CT scan, which showed that she had a lacerated liver and a small lung contusion.

A radiologist advised that the girl needed to be examined by a surgeon but their report did not show up in the hospital’s clinical records portal. Surgical staff only learned about the recommendation hours later when a junior doctor independently looked at the scan results.

“The 12-year-old slept through the night, accompanied by their whānau at her bedside, under the false assumption she was safe and receiving care with reasonable skill,” Wolf claimed in the report. “At any moment, the patient could have decompensated and died, as some do with liver lacerations.”

By “luck and chance” the girl’s liver stopped bleeding on its own without needing surgery, Wolf wrote. Her family was oblivious to their near-miss until Wolf told them about it later. (Wolf declined to comment and the girl’s family could not be reached.)

The incident was not isolated, Wolf claimed, but representative of widespread safety risks at the hospital arising from flawed IT systems. He claimed that similar problems were happening routinely in other hospitals across the country.

In response to Wolf’s disclosures, Te Whatu Ora ordered a review of Hawke’s Bay’s radiology service. In April 2023, the reviewers issued a damning report which found that years of poor performance and unsafe practices had forced staff to adopt risky workarounds, fostered a culture of “learned helplessness”, and caused documented harm to patients.

At the heart of the problems was an IT system that was plagued with technical problems, including that prior patient studies were not visible, scans for different body parts of the same patient were not linked, and reports were not delivered to the clinicians who requested them.

The review indirectly mentioned one case of known harm to a patient. In 2016, Lindsay Collinson was found by a CT scan to have a possible malignancy, but the results were not read by a clinician until more than a year later. He died of cancer soon after. His partner, Toni Woods, spoke to the Herald in 2020 after the Hawke’s Bay district health board was admonished by the Health and Disability Commissioner. Woods has since died.

Toni Woods spoke to the Herald in 2020 after Hawke's Bay DHB was admonished for IT failures in the care of her partner Lindsay Collinson. Photo / Paul Taylor

Te Whatu Ora initially refused to release the findings of the April 2023 review. Wolf was furious at that decision and wrote to the Chief Ombudsman Peter Boshier accusing Te Whatu Ora of a “conspiracy” to avoid disclosing safety risks to the public. Te Whatu Ora denied there had been a deliberate attempt to mislead the public and said it acted on legal advice.

Te Whatu Ora reconsidered in August after the Herald revealed that Wolf had escalated the issue to the Ombudsman and it published the reviewers’ full findings and recommendations. Since then, Wolf’s disclosures have reverberated across the health service, prompting scrutiny from external agencies and a flurry of activity among senior executives.

Te Whatu Ora says it has taken Wolf’s concerns extremely seriously and committed significant resources to address the problems he raised. But months later there has yet to be a full public accounting of the extent of patient harm caused by the problems at Hawke’s Bay Hospital over the past decade and the impact they had on individual patients.

Contact the reporter if you have more information: alex.spence@nzme.co.nz

The reports obtained by the Herald add substantially to the information in the April 2023 review, including details of several incidents in which patients were harmed or experienced close calls.

In one example, Wolf claimed that an orthopaedic surgeon was about to perform emergency surgery on a teenager who had suffered major fractures but had to wait because a computer in the operating theatre did not have enough memory to open CT images. The emergency procedure was delayed by up to 15 minutes while the surgeon went around other rooms trying to open the scans.

In an email quoted by Wolf, the surgeon later said that the hospital’s IT system “presents a serious risk to patients and in my opinion, it is only a matter of time before someone comes to serious harm or worse still results in a death”.

In other incidents cited by Wolf, a 27-year-old patient allegedly experienced a delay in care of more than 400 days and “will suffer permanent disability”; and a woman with a heart condition allegedly spent a month more than she needed on risky anticoagulant medications because her GP did not receive a radiology report.

Wolf also described technical failures including the accidental deletion of an entire imaging database in December 2022, which caused days of disruption to radiology services. Later that month, a CT scanner near the end of its life broke down for a week, which he said required more than 100 patient appointments to be rescheduled.

The Herald filed an Official Information Act request seeking Wolf’s reports in August but Te Whatu Ora has still not provided them. In the meantime, we obtained the reports separately from other sources.

Te Whatu Ora declined to comment on the incident involving the 12-year-old girl because of its obligation to protect patients’ privacy.

Dr Richard Sullivan, its chief clinical officer, said: “Te Whatu Ora continues to take matters related to Hawke’s Bay radiology services very seriously including continued progress implementing the recommendations of an earlier review.

“Our team in Hawke’s Bay is committed to providing radiology services for both acute and elective patients; people in the area can be assured they will receive effective services.”

Measures that Te Whatu Ora is taking to remedy the systemic problems in Hawke’s Bay include setting up a senior oversight group that meets monthly, technical upgrades, changes to clinical governance, and an audit of patient harm. The radiology department is also getting a new CT scanner and refurbished premises.

Health Minister Dr Shane Reti said he could not comment on the specifics of an “operational issue” but has been assured by officials that Te Whatu Ora has a plan to address the problems. “New Zealanders go to health care settings expecting a good standard of care and that is what I also expect our system to deliver,” Reti said.

Reti added that he expects Te Whatu Ora to “fulfill its obligations for any information request”.

Alex Spence is an investigative reporter and feature writer who tends to focus on social issues such as health and mental health. He joined the Herald in 2020 after 17 years in London where he worked for The Times, Politico, and BuzzFeed News. He can be reached at alex.spence@nzme.co.nz or by text or secure Signal messaging on 0272358834.