A man from Hawke's Bay, New Zealand, died after a CT scan that suggested cancer was not read for more than a year, stated a report published online on 8 June by Radio New Zealand (RNZ).
The country's health and disability commissioner, Anthony Hill, found in an investigation that "multiple systems failures" contributed to the man's death, including the fact that the CT report was not made available on the hospital's electronic record system and clinicians were not aware that they could view it on the hospital's radiology information system, RNZ reported. The CT was performed in 2016 and showed suspicious findings, but it was not read until more than a year later. The man was diagnosed with metastatic cancer soon after and has died.
The man's death is the result of a failure of the Hawke's Bay District Health Board, according to Hill. It has identified the IT error that caused this outcome and has put into place a number of changes to its clinical portal system, the RNZ said.
"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," Hill said in the RNZ report.
Hawke's Bay District Health Board has accepted Hill's findings, and has offered an apology to the man's wife, noted RNZ.
