The Health and Disability Commissioner has ruled against the actions of a sonographer and Waitemata District Health Board in the misdiagnosis of an ectopic pregnancy and discussions about the return of tissue.

Commissioner Anthony Hill today released a report finding the sonographer, who worked for a private practice, and district health board (DHB) were in breach of the Code of Health and Disability Services Consumer's Rights in relation to the care they provided to a pregnant woman.

A 19-year-old pregnant woman was referred for an ultrasound after telling her doctor she had some pain in her left side.

The ultrasound was performed by a trainee sonographer, who informed the supervising sonographer that she thought the woman had a live ectopic pregnancy (a pregnancy outside the uterus) in the right fallopian tube.


The trainee sonographer then rescanned the woman while the supervising sonographer observed.

The supervising sonographer did not see a fetal heartbeat in the right fallopian tube and the images were not convincing for this diagnosis. However, she accepted the trainee's findings.

The trainee sonographer advised the radiologist that she and the supervising sonographer both thought the woman had a live ectopic pregnancy. The radiologist telephoned the woman's GP and recommended the woman be referred to hospital for urgent specialist assessment.

The woman underwent surgical removal of her right fallopian tube at the DHB, but subsequently was found to have a normal intrauterine pregnancy.

Prior to surgery, she was provided with a consent form with a tick box relating to return of tissue but it was not discussed with her adequately and this section of the form was not completed.

After surgery, the woman requested the return of her right fallopian tube. Subsequently, it was discovered that all of the tissue had been used during testing, however the woman's tissue was later returned to her.

Commissioner Hill considered that the supervising sonographer should have taken over the care of the woman and re-assessed her herself, as well as convey any doubts about the diagnosis to the radiologist. Hill was critical that the radiologist was aware that the images were not convincing for this diagnosis, but failed to take further action in this respect.

Hill acknowledged the trainee sonographer misinterpreted the scan, but this was mitigated by the fact that she was a trainee at the time and appropriately extended the examination and consulted her supervisor.


Hill said the process undertaken in regard to returning the woman's tissue was suboptimal. Numerous staff did not follow the detailed policies in place at the DHB.

Hill found that the DHB did not provide the woman with information that a reasonable consumer would expect to receive regarding the process for the return of tissue.

On the basis of the information available to hospital staff at the time, Hill considered it was reasonable to carry out surgery to remove the woman's right fallopian tube, but it would have been prudent for staff to have kept in mind the differential diagnosis of an early intrauterine pregnancy.

Hill recommended the trainee sonographer, supervising sonographer and radiologist have an independent peer perform a quality review of their work and also recommended the radiology clinic review its supervision processes for trainee sonographers.

Hill also recommended the DHB use the case as an anonymised case study for clinical staff, and conduct training for all obstetric/gynaecology staff at the hospital on the cultural and emotional significance of the return of tissue and body parts, and on its policy for the return of tissue and body parts.

Hill recommended that the trainee sonographer, supervising sonographer and DHB apologise to the woman (the radiologist had already apologised).