A New Zealand radiologist has breached that country's Code of Health and Disability Services Consumers' Rights due to poor reporting of a CT scan, according to coverage from the New Zealand Doctor.
The error may have delayed a bowel cancer diagnosis for a woman who died of a blood infection from a bowel obstruction, New Zealand Doctor said.
New Zealand deputy health and disability commissioner Carolyn Cooper gave notice of the breach in a report released on 12 August, writing that the radiologist "[failed] to provide an appropriate standard of care."
The woman had been quite ill and presented at Whangārei Hospital with a noticeable abdominal mass. But the radiologist's report on a CT exam she underwent only flagged "two minor issues but 'no obvious malignancy,' " according to New Zealand Doctor. The woman was readmitted to the hospital several weeks later, and the radiologist re-reviewed the CT scan, finding an abnormality and reporting the need for further assessment, but this was not performed for another two days, when the woman underwent an MRI which identified a cancerous mass blocking her bowel. She died within a few weeks of septicemia due to a perforated bowel caused by the tumor.
"I am critical of the alert system and the process that was in place for documentation of addendums [at Health NZ Te Tai Tokerau]," Cooper said in the New Zealand Doctor report. "Clear documentation of when and how the addendum was conveyed to the relevant parties could have prevented confusion in [the patient's] care and the subsequent delay caused by the confusion
The Royal Australian and New Zealand College of Radiologists (RANZCR) report-writing guidelines include a section on managing discrepancies (see https://www.ranzcr.com/college/document-library/radiology-written-report-guideline), and there is also a document on communication of urgent findings (see https://www.ranzcr.com/college/document-library/cliniradiology-critical-results-and-adverse-outcomes-notification).
