Southland cancer patient died after radiologist makes scan error

A radiologist whose “serious individual failures” missed the signs of liver cancer that killed a Southland Hospital patient continues to work in public and private hospitals.

The radiologist also misdiagnosed another Southland patient who was subsequently diagnosed with terminal liver and pancreatic cancer.

The consultant radiologist, identified in reports released by Health and Disability Commissioner Morag McDowell today as Dr B, no longer works for the Southern DHB (now Te Whatu Ora) and faces possible legal action..

The first report concerned a man in his 70s who had a CT scan in January 2018 at Southland Hospital to investigate a mass in his liver.

Dr B interpreted the CT scan and reported that the mass was not cancerous.

At a follow-up CT scan in January 2019, the man was diagnosed with cancer that had spread to other parts of his body. He subsequently died from his illness.

McDowell found the radiologist failed to provide services with reasonable care and skill.

She was critical that Dr B did not correct an incomplete CT protocol when he became aware that the imaging was inadequate, which ultimately resulted in substandard interpretation of the CT scan.

She acknowledged that while Dr B had since been reviewed and made changes to his practice “there is a public interest in accountability for his serious individual failures and major shortcomings of care”.

McDowell noted that Dr B continued to work in the private and public sectors.

Dr B told the investigation he had a particularly high workload in 2018, and at the time of the cases was the only radiologist in the department who was reporting on MRI scans.

He also noted that SDHB’s investigation showed that he had reported more scans than other radiologists from January to May 2018.

The second report investigated the care provided by the same radiologist at Southland Hospital after a man came to the Emergency Department with stomach pain in 2017.

After an MRI in 2018, Dr B reported a benign liver lesion and stated that no further follow-up was required. In 2019, the man was admitted to hospital with abdominal pain.

An ultrasound identified a substantial increase in the size of the original liver lesion. An internal radiology meeting found the MRI the radiologist read in 2018 was consistent with liver cancer. The patient was subsequently diagnosed with terminal liver and pancreatic cancer.

McDowell found Dr B breached the Code of Health and Disability Services Consumer’s Rights.

In the first report McDowell found him in breach for failing to provide services with reasonable care and skill. She was critical that the radiologist did not correct an incomplete CT protocol when he became aware that the imaging was inadequate, which ultimately resulted in substandard interpretation of the CT scan.

She determined that Southern DHB did not breach the Code, although she identified several areas for improvement.

In the second report McDowell found the radiologist in breach for misdiagnosing the man’s liver lesion on an MRI as benign when in fact it was suspicious of liver cancer.

This error “fell significantly below the standard of care reasonably to be expected of a consultant radiologist”.

Te Whatu Ora was also found to have also breached the code for an unacceptable delay in commencing an internal investigation into the radiologist’s misread.

McDowell has referred the radiologist to the commissioner’s director of proceedings to determine if legal proceedings should be taken.