The results of a scan of an overdue baby with medical concerns were not sent to the mother's midwife, possibly contributing to the death of the baby, according to a report published on 17 November in the New Zealand Herald.
In 2021, a radiology practice, Pacific Radiology, miscoded an ultrasound exam conducted at 41 weeks that showed low amniotic fluid – which resulted in the scan being sent "to nowhere," rather than to the mother's midwife, the Herald reported.
The mother filed a complaint with New Zealand's Health and Disciplinary Commission, which has found that "Pacific Radiology and the midwife breached the woman's right to care by not sending the scan through and not following up on it," according to the Herald.
Deputy Commissioner Rose Wall said the findings of the scan were significant and required priority communication to the midwife, but a “coding error” meant they weren’t sent.
“I am highly critical that Pacific Radiology was aware that it was using an IT system that held ‘empty’ codes, which, if selected, would result in the report in question going ‘nowhere’," she pointed out. "I am also critical that it appears that no checking systems or policies were in place for such cases … whether that be within the system itself, and/or follow-up by frontline staff.”
Chief medical officer for Pacific Radiology, Dr. Adrian Balasingam, noted that the technical issues with reporting had now been resolved and will not recur, the article continued.
“Pacific Radiology has recently updated its Communication of Actionable Imaging Findings Policy for Radiologists, aligning it with international best practices to ensure urgent communication of life or limb-threatening conditions to the clinicians caring for their patients," he said. “The radiologist involved in this case was devastated by the outcome and has since adapted their practice."
