Woman dies of cancer after suspicious lung X-ray result slips through DHB's cracks

No medical follow up of a suspicious lung x-ray result was done until the woman returned to hospital 20 months later, by which time it was too late. Image / 123rf

A woman who sought hospital help for a cough and had an X-ray whose suspicious findings were overlooked, died from cancer nearly two years later.

By the time cancer was diagnosed, cells from the apparent lung tumour where the original "suspicious density" had been identified in the X-ray had spread to other parts of her body.

The woman was 66 when she first sought help at a Southern District Health Board emergency department in 2013, according to a report published today by Health and Disability Commissioner Anthony Hill.

He identified failings in the DHB's systems, concluding it had breached the code of patients' rights by failing to provide care of an appropriate standard to the woman, whom he names only as "Mrs A".

At the ED, the woman was given nebuliser treatment for what the doctor diagnosed as chronic obstructive pulmonary disorder and acute asthma. An X-ray was done to check for pneumonia and the doctor decided the image showed no signs of this disease.

Several days later the radiologist's formal X-ray report, which identified a 15cm by 10cm mass and recommended a follow up X-ray or CT scan, was sent to the ED doctor. She reviewed it two days later. She was going on leave the next day and did not acknowledge the electronic report as she wanted to discuss it with radiologists.

The results weren't urgent and she considered it appropriate to wait until returning from her 10-day break.

When "Dr C" returned from leave, the X-ray results were no longer visible in the
memo tab of Dr C's inbox, and she did not recall the report.

The woman, "Mrs A", did not receive the recommended follow-up imaging and the X-ray results were not sent to her.

About 20 months after the X-ray, Mrs A returned to the ED having felt unwell for the
last few days with a constant headache, right-sided weakness, poor co-ordination, and having recently experienced eight to ten falls.

A review of her electronic clinical history resulted in the discovery of the non-actioned X-ray report.

Hill's clinical adviser, Dr William Jaffurs, said medical checks revealed metastatic cancer, "with a primary apparently in the right lung where the chest X-ray done in 2013 showed a suspicious density". The woman received palliative radiotherapy and died in a hospice.

Hill said the DHB failed to have in place an appropriate system for the management and acknowledgement of test results. While a system was in place, clinicians were not trained adequately to use it.

"There was clearly widespread misunderstanding within SDHB's ED regarding the functionality of the IT system, which clinicians should have been able to rely on and use adequately.

"There was inadequate initial and ongoing training in relation to the system. This failure resulted in Dr C not following up on Mrs A's report. In addition, SDHB did not have in place an appropriate system to ensure that Mrs A's GP received the X-ray report, and did not have a process to ensure that reports or results did not go unacknowledged by SDHB clinicians."

Hill made a number of recommendations on auditing and improving electronic results reporting systems.

The DHB said in a statement it had apologised to the family and friends of the woman whose diagnosis was missed.

"We were able to apologise to the patient personally when the error was discovered. Sadly this discovery was too late to ensure she received the treatment she needed," said chief medical officer Dr Nigel Millar.

"We profoundly regret this error, and take seriously our responsibility to learn from the situation to prevent it occurring again, and to supply health services that are safe and reliable.

"The ... commissioner has made a number of recommendations relating to our processes for managing test results within our IT system, which we accept without reservation.

"Southern DHB has also invested significantly in projects and systems to address this underlying issue.

"Our investigations, and those of the HDC, highlighted a lack of consistent processes across the DHB to view, action and record acknowledgement of test results using our IT systems.

"While we must recognise that the overwhelming majority of test results were viewed and actioned as needed in the provision of high quality care, the lack of a standardised process represented an unacceptable patient safety risk.

"Following the event, specific risk areas associated with the electronic system in use at the time were addressed.

"Further, and significantly, we have since moved to the South Island regional electronic system Health Connect South. This now provides a more transparent system for identifying and managing unacknowledged results. We are committed to ensuring this new system is correctly used and robustly managed to prevent a repeat of this tragic event.

"As well as providing better tools for managing the results within a hospital setting, GPs also can now more easily access results that appear in their patients' hospital records, better enabling them to ask questions and support ongoing treatment plans.

"We also encourage patients to take an active interest in their health records and if they have any questions about tests that have been taken, please do not hesitate to ask for the result."