SDHB apologises for missed diagnosis as patient's cancer spread
The Southern District Health Board has apologised to the friends and family of a patient, after information about a mass on her lung was misplaced, and she later died.
Health and Disability Commissioner Anthony Hill released a decision on Monday after it found the SDHB to be in breach of the Code of Health and Disability Services Consumers' Rights.
The decision detailed the 66-year-old woman's ordeal and the functionality of the SDHB's IT system.
In 2013, the patient came into the Southland Hospital Emergency Department (ED) with a cough and chest tightness.
An X-ray was taken, but the ED doctor did not note anything of concern.
Five days later, the formal radiologist's report regarding the X-ray identified a 15x10mm mass and recommended a chest X-ray or a CT scan in six weeks' time.
The report was sent to the ED doctor's email inbox and while she reviewed the results, she wanted to review the X-ray further and discuss it with the radiology consultants.
"She said that the results were not immediately urgent, and she considered it appropriate to action them on her return [from 10 days leave]," the Commissioner's decision says.
"She assumed that the result would still be visible in the memo tab on her return, and was not aware that the memo would drop off from her view after 24 hours."
However, when the doctor returned from leave, the patient's X-ray results were no longer visible in the memo tab of her inbox, and she did not recall the report.
Nearly two years later, the woman went to the Southland Hospital ED with several problems and it was found she had cancer, originating from her lung and it had spread to her brain.
She died a short time later.
Southern DHB chief medical officer Nigel Millar said the DHB was able to apologise to the woman when she was alive, but the discovery was too late the ensure she received the treatment she needed.
"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," he said.
"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," he said.
Hill said while the SDHB had a system for the management and acknowledgment of test results, it was not appropriate and 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 use easily and rely on," he said in his report.
Hill found the SDHB's IT system allowed results to disappear from the view of the clinician's memo tab. Once results were opened/viewed in the memo tab, after 24 hours, regardless of whether results were acknowledged, they dropped to the bottom of the queue.
All unattended and unacknowledged reports remained in the clinician's "unacknowledged work list", but the ED staff were using only the memo tab.
Hill listed several recommendations in his decision, including having the SDHB consider having a warning system added to its electronic IT system to alert clinicians to the existence of unacknowledged results.