Government authorities are faulting a general medicine practitioner for failing to order a radiologist-recommended follow-up CT that would have caught a deadly lung cancer case weeks earlier.
An octogenarian visited the emergency department three times in August 2019 complaining of chest pain, with doctors diagnosing angina via X-ray. On the third visit Aug. 29, the reporting radiologist noted a mass on his right lung and recommended a CT scan.
However, the man was never informed about his condition, and the referring physician failed to take action to close the loop, New Zealand’s Health & Disability Commissioner reported Monday. “Mr. A” returned again Oct. 6 experiencing pain in his right side, weakness and immobility. Doctors discovered he had a rapidly growing mass in his right lung, which led to his eventual death in 2020.
“Systemic issues at Canterbury [District Health Board] constituted a failure to ensure that the man had all the information that a reasonable consumer in his circumstances would expect to receive,” Deputy Health and Disability Commissioner Deborah James said in an Aug. 14 news announcement.
Mr. A also had visited the ED several times prior to August 2019. His medical history included diabetes, heart disease, high blood pressure and elevated cholesterol, all influencing the original angina diagnosis. The Aug. 29 radiologist report noted a 19mm lung nodule, which had grown to 45mm by Nov. 5, when providers also performed a biopsy. General medicine physician “Dr. B” accepted the patient’s radiology report on Sept. 2, but failed to take any further action. He told authorities during the investigation that he was treating another patient with a similar name that day, and he had received both reports around the same time. The physician also failed to document a conversation he had with a respiratory therapist about Mr. A.
“[Dr. B] said that this is because the other patient’s radiology report showed almost identical findings to Mr. A’s, and this led him to believe, mistakenly, that both the reports were the other patient’s,” the report noted. “Consequently, he marked Mr. A’s report as accepted in the mistaken belief that he was accepting the other patient’s results.”
The man opted for radical radiotherapy to attempt to cure his cancer, rather than a palliative approach, but the treatment failed. Mr. A filed a complaint with the commissioner prior to his death—charging that his frequent ED trips could have been an indicator of lung cancer—which launched the investigation that produced Monday’s report.
James issued several recommendations in response to the incident. She wants an audit to ensure that providers are complying with a requirement to update discharge summaries to denote any abnormal imaging results after a patient is released. This updated summary also should be sent to the patient’s primary care doc, she added. Authorities also want the introduction of a new requirement that discharge summaries note any results that are still awaiting reporting. And they want a second audit to ensure compliance with a requirement to disclose the findings to the patient within 24 hours, with communication documented in the individual’s medical records.
James admitted that the four-week delay in diagnosis “may not have affected the outcome.” However, Mr. A’s healthcare experience represented a “serious departure from the standard of care.”
“The deputy commissioner noted that despite several different clinicians in two different departments being aware of the failure to action the radiologist’s report, no clinician took responsibility for ensuring that the man was informed of this at the earliest opportunity,” the report noted. “The deputy commissioner considered that this failure was attributable to systemic issues … and constituted a failure to ensure that the man had all the information that a reasonable consumer in his circumstances would expect to receive.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.