A woman who sought help for weight loss and abdominal pain died after her pancreatic cancer was overlooked.
Deputy Health and Disability Commissioner Rose Wall said in September 2016 the woman was referred to the public hospital for a CT scan of her abdomen and pelvis.
A radiologist read and reported the scan the same day and detected no abnormalities in the abdomen or pelvis. As a result, nothing was followed up.
Then, about seven months later abnormal blood tests prompted a gastroenterologist to review the CT scan and discovered the radiologist had missed the cancer.
Sadly, it was too late and the woman died.
The radiologist told HDC that pancreatic cancers were notoriously difficult to detect as a distinct mass lesion.
But said he had no explanation as to why he had not detected this pancreatic head mass lesion on the woman's scan.
"Had I appreciated the cancer I would have recommended a follow-up MR examination for her."
The radiology service told HDC that peer reviewing in day-to-day practice was not standard practice for imaging reporting from the public hospital.
In New Zealand, a double reading of a scan occurs routinely only in particularly complex imaging such as mammography, and would not be considered for a CT scan of the abdomen and pelvis, as this is not considered to be complex imaging.
The radiologist was ordered to give a formal apology to the woman's family for breaching the Code of Health and Disability Services Consumers' Rights.
Wall also requested a progress report on an implementation of a peer audit system across the radiology service.