A man who waited three months for the report from his chest x-ray at Wellington Hospital is now dying of cancer.
The man, 72, was the victim of "unacceptable" delays in the reporting of x-ray films during chronic understaffing of the hospital's radiology department in 2004, Health andDisability Commissioner Ron Paterson has ruled.
In a report released today he said the patient "fell through the cracks" when his x-ray, revealing a mass on his lung, was not followed up.
The man learned he had advanced, incurable lung cancer nearly three years after the X-ray was done.
In his report, Mr Paterson said that when the man's x-ray report was finally completed after a three-month delay in 2004, the radiologist did not phone his doctors to tell them he had found a "suspicious" mass.
The oversight was not revealed until the patient was admitted to hospital with severe pneumonia in March last year.
"His lung cancer should have been detected at the time, so that appropriate treatment could have been considered," Mr Paterson said.
The man's only option now was palliative care.
In 2004 another patient died of pneumonia and respiratory failure after it took nearly 30 hours to review his chest X-ray and blood tests. Mr Paterson identified numerous failings in that case.
In his latest report, he said he was satisfied Capital and Coast District Health Board had made "extensive and necessary changes".
The radiologist involved in the latest case, "Dr D", told Mr Paterson that Wellington Hospital radiologists faced systemic problems and chronic understaffing in 2004 which led to an "unacceptable" backlog of X-rays.
Films were often not being reported until they were up to six months old, he said.
Dr D said he regretted not calling the patient's surgical team or GP after finding an abnormality on the X-ray.
Capital and Coast chief medical officer Geoff Robinson said significant improvements had been made in radiology since 2004, with new computer systems introduced and extra staff recruited.
