A general practitioner is being blamed for a two-year delay in one woman’s cancer diagnosis, after the physician overlooked CT results on the individual’s discharge summary.

New Zealand’s Health & Disability Commissioner shared the details of the malpractice case in a report published Aug. 21. Unnamed 60-year-old “Ms. A” first visited a public emergency department in early 2018 after sustaining an injury. She underwent CT and was discharged with a diagnosis of a soft tissue injury to her shoulder, the report detailed.

The initial discharge summary, however, did not include the results of the scan, which were not yet ready to be viewed. Providers amended the summary later that day and again two days later to include a recommendation for a follow-up MRI after discovering a 17cm mass on Ms. A’s neck. But the referring physician overlooked the CT report, assuming this third amendment was a duplicate of the initial two summaries.

“I unreservedly apologize for missing an amended report from your discharge summary dated 24 Feb. 2018 from the ED department [of the hospital],” “Dr. B” wrote in an apology letter two years later, according to the commissioner. “The report states that I was called and informed of the scan, and that I would organize an [ear, nose and throat] referral. I am incredulous that I would not have done this immediately as this is what I do when I receive something of this nature.”

Two years later, Ms. A returned for a visit to an urgent care clinic, where providers discovered the previously overlooked CT results. She underwent surgery to remove the mass in her neck, which was diagnosed as a metastasized squamous cell carcinoma. The commissioner’s office blamed the general practitioner for the mistake, after he filed the discharge summary without first checking it for any new information.

“In my view failure to act on the woman’s scan results and recommendations of the public hospital was a human error and the responsibility of the GP alone,” Deputy Commissioner Carolyn Cooper said in a news release.

In response to the incident, Dr. B has made changes to his clinical routines, including “meticulously reading all duplicate documents,” and closing his practice to new patients. This, Cooper and colleagues noted, will allow more face-to-face patient time, along with eliminating after-hours work to ensure a better work-life balance. The commissioner additionally recommended a sample of discharge summaries and clinical records handled by the physician.