8 Jun 2020

Hawke's Bay DHB 'multiple systems failures' led to man's death - commissioner

6:07 pm on 8 June 2020

A Hawke's Bay man died after a CT scan diagnosing cancer was not seen by a doctor for more than a year, the Health and Disability Commissioner has found.

MRI examination film of patient's head as a medical diagnostic background.

(File image). Photo: 123RF

Commissioner Anthony Hill's report into the case found "multiple systems failures", including an "IT issue", at the district health board which led to the man's delayed treatment and his death.

The man had a CT scan in 2016 that revealed several concerning findings, including possible malignancy.

"However, an IT issue meant that the radiologists' scan report was not made available on the Electronic Clinical Application system used by clinicians, and clinicians were also not aware that they could view the report on the Radiology Information System," Hill said in his report.

"Sadly, the man passed away."

The man's scan report was first seen by a clinician more than a year later, and he was diagnosed with metastatic adenocarcinoma (cancer) shortly afterwards.

The commissioner was also critical of the radiologist for the standard of his CT scan report.

It was "unacceptable" that it took more than a year for the investigation reports to reach the ordering clinician, he said.

"HBDHB [Hawke's Bay District Health Board] has a responsibility to ensure that there are appropriate systems in place so that clinicians receive important information relating to patient investigation results."

He noted that the DHB had "identified and rectified the IT error" that occurred in this case, and that its new Clinical Portal was expected to improve access to radiology reports.

A review of the new clinical portal and of waiting times to access the DHB's cardiology and rheumatology clinics was also recommended by the commissioner.

The DHB has since provided a written apology to the man's wife.

It said it had also accepted the Commissioner's findings.

"Since this report, and as specified by HDC, HBDHB has implemented a number of changes, including implementing the Clinical Portal application system so access to radiology reports for clinicians is improved."