A radiologist has been faulted for failing to detect an abnormality in the spine of an elderly woman.
Health and Disability Commissioner Anthony Hill has found the unnamed radiologist in breach of the code of patients' rights and has told him to write an apology to the widower of the patient, who has died.
The woman was 68 when, in 2013, she went to her GP because of severe pain in her lower back and hips.
She was referred for an X-ray, from which the radiologist identified multi-level chronic disc degeneration, Hill's report says. But he did not detect in the L2 vertebra a "lytic lesion", a light area in otherwise dense bone which suggests something has destroyed or replaced that part of the bone.
Several months later, the woman, "Mrs A", still in pain, sought help from specialist services at a district health board, was discharged, received home support, and was later admitted to hospital.
Investigations identified the lytic lesion and spinal cord compression. She was transferred to another hospital some days later where multiple myeloma was diagnosed and she had spinal stabilisation surgery.
"Her recovery was difficult, and she was transferred back to hospital 1 ...," Hill said. "Mrs A developed hospital-acquired pneumonia, and her condition began to deteriorate. She died a short time later."
Hill made "adverse comment" about the radiology service where the radiologist worked, because it was understaffed. The radiologist had an injury at the time which slowed his work. The service tried to arrange a workplace assessment for him, but in the interim his workload remained the same and "nothing more was done in the interim to ensure that Dr B could continue to carry out his work appropriately".
The radiology service has since made a number of changes, Hill said, including adjusting its staffing levels, monitoring whether the number of radiologists is sufficient to meet the workload demand, having a contract with another radiologist agency to provide remote reporting services when necessary, setting planned leave at two radiologists at a time, and creating protected times where radiologists can work uninterrupted.
The service also plans to decrease interruptions from technicians for advice by reviewing its CT and MRI protocols, and to reduce the time radiologists have to spend on vetting referral requests by considering changing this to an electronic process.