HDC deputy commissioner Carolyn Cooper’s investigation of the case, released today, reveals the unnamed woman had an MRI scan on April 21, 2016, as part of a preoperative work-up before planned hip replacement surgery.
The MRI scan showed an “incidental finding of a tumour” on her right kidney.
The woman, then aged in her 60s, was referred by her GP to Dr C for further investigation and assessment.
A week later the woman, identified as Mrs A, went to a urologist at a private hospital who said it was likely that her kidney would need to be removed to treat the cancer.
On May 2, 2016, Mrs A had the staging CT scan of her chest and abdomen at the radiology service by radiologist Dr D, who also found an abnormality in the woman’s lung.
The “area of consolidation” in the right lung was not mentioned in the “comment” section of the CT scan report, and there was no recommendation for follow-up.
The radiologist did not make a diagnosis or recommend follow up and the report was sent to Dr C and copied to Mrs A’s GP.
Dr C saw Mrs A on May 14 and a plan was made for surgery to remove Mrs A’s right kidney.
In her report, the deputy commissioner said there was no evidence in clinical records that Dr C discussed with Mrs A the abnormality in the lung from the CT scan.
Dr C said he couldn’t recall discussing it, while the woman’s family said it was not discussed with her.
The urologist did not discuss the finding of the lung abnormality with Mrs A’s GP, and no further scans were arranged.
She had successful kidney surgery on May 20, 2016.
She was sent for a postoperative chest X-ray the same day and there was no comment regarding the tumour in the right upper lobe of her lung.
She was discharged five days later and went back in July for a six-weekly review. Dr C told the HDC that at that point the cancer “had been fully contained by having her kidney removed”.
On September 15 the same year, Mrs A had surgery for a total hip replacement.
Dr C next saw Mrs A on February 2, 2017, for her six-month follow-up review and in a letter to her GP, said she was doing “remarkably well”.
“Nothing more needs to be done. I will see her back here in six months’ time and will organise a CT scan after that.”
However, Dr C did not see her again - as no follow-up appointment was made at the time - so no further CT scan was arranged.
The woman’s health then declined, with her reporting mid-chest pain through to her back, making her cough.
A CT scan was arranged and an advanced lung tumour was discovered on her right lung that had spread to her lymph nodes and other parts of her body.
A week later, she went to hospital with chest pain and significant breathlessness. She was admitted to hospital but died two weeks later.
In a letter to the woman’s husband, a respiratory physician who cared for the woman in her last weeks said her cancer was “totally avoidable” and should have been identified by Dr D, the radiologist.
He told Mrs A in hospital that he was, “so sorry[,] you [should not] be in this position, and you should not be dying”.
In response to questioning from the HDC in 2019, Doctor C said: “[I]f the radiologist consider[s] that there is anything abnormal in the [imaging], it should be highlighted in the report ... If the radiologist is concerned that the imaging shows sinister lesions, then it should be mentioned and advice given as to what [X]-rays/scans should be done for follow-up”.
He also apologised to the family.
“I am truly sorry for her missed appointment with myself,” admitting it would have been “quite appropriate” that he had organised a six-month follow-up, or at least a six-week follow-up appointment to arrange a CT of consolidation in her lung.
“Because her chest [X-ray] post-operatively did not show any flare-up of that consolidation and she felt so well, I had no concerns to CT scan earlier.”
The deputy commissioner recommended that the urologist apologise in writing to the woman’s family, and provide an evaluative report on the effectiveness of the changes that were implemented as a result of this case, and advise of any further changes made or considered as a result of the evaluation.
She also recommended that the radiologist arrange for a clinical peer review of the standard of his radiology reporting.
A copy of the report has been sent to the Medical Council of New Zealand, with the names of the doctors involved.
