Radiology referral system change led to deadly cancer diagnosis delay, government watchdog says

A change to one hospital’s radiology referral system was the key factor in significantly delaying a patient’s cancer diagnosis, leading to her eventual death, a government watchdog reported recently.

The case dates to 2017, when the unidentified woman began undergoing surveillance ultrasounds every six months, as she was susceptible to liver cancer. However, the scans inexplicably ceased in 2019, according to the results of an investigation released this month by New Zealand’s Health & Disability Commissioner. “Mrs. A” later presented to an emergency department in 2022, when a CT scan revealed terminal cancer.

She died shortly after in hospice care, prompting her son to file a complaint with the watchdog agency tasked with examining consumer healthcare complaints. An investigation by the office revealed that, in April 2019, the hospital switched to a new system for electronic imaging referrals. After the change, the system stopped accepting repeat or recurring requests, including those for regular surveillance ultrasounds. This meant that each future scan required a new referral.

“I consider that the most significant factor in the delay of Mrs. A’s cancer diagnosis was the change of radiology referral systems without appropriate safety nets in place to pick up those patients who were prescheduled for appointments, including surveillance scans, and would require new referral for these to continue,” the July 1 report noted.

Mrs. A had her last outpatient appointment with a gastroenterologist on Feb. 13, 2019. This was a follow-up from an inpatient admission for chest pain and constipation (not related to the most recent surveillance ultrasound). At the time, she no longer had the same symptoms but was concerned about a “funny feeling in her head and bilateral leg oedema.” The doctor determined this was likely due to low albumin related to cholestatic hepatitis.

Mrs. A was advised that a November 2018 MRI had shown a liver nodule but no cancer, with further imaging needed in a year. At the time, her gastroenterologist advised that further follow-up ultrasounds had been booked to assess ascites around the liver. The woman later visited the hospital for other reasons, including acute coronary disease. But despite seeing other specialists, no one considered whether she was due for liver follow-up, nor requested the necessary ultrasounds.

After the final scan in April 2019, the report noted a nodular liver surface with coarsened echotexture, in keeping with liver cirrhosis. No focal mass lesions or ascites were identified.

The hospital switched to the new referral system the same month. At the time, the radiology manager sent a message to clinical staff, advising that repeat referrals on the same form were not supported by the system. Instead, clinicians would need to create a new referral ticket for each subsequent exam. Staffers made this change amid concerns that radiology was not receiving regular updates about a patient’s status. Repeat referrals also were impacting scheduling, with appointments not being scheduled or canceled “appropriately for the consumer’s current presentation.”

“An email discussion between the radiology manager, chief medical officer, and clinical directors also took place to consider how best to manage these changes with surveillance programs,” the report noted. “It was suggested and agreed upon by the radiology service that the clinical nurse specialist managing the surveillance program would have delegated authority to order surveillance requests, on behalf of a medical specialist.”

However, no further requests for a follow-up ultrasound were received by the radiology department for Mrs. A. And no one at the hospital scheduled the six-month follow-up appointment with her specialist, due to a processing error in the outpatient appointments office.

“I accept Health NZ’s reasons for no longer accepting the same referral for multiple surveillance scans,” Deputy Commissioner Dr. Vanessa Caldwell, MBA, said in the report. “However, I am critical that there were no checks to determine those already on surveillance schedules and how those would be continued to be scheduled as required. In the context of a stretched resource in gastroenterology, I consider that it was not the sole responsibility of the referrer (in this case, the gastroenterologist) to make new referrals for all patients under surveillance. A system with safety-netting (e.g., a message to [general practitioners] about the change) should have been in place to support them to do this.”

Caldwell recommended several changes in response to the incident. Those included updating clinic letters to request that primary care docs organize surveillance scans, if a patient has not received one within 12 months. Health New Zealand also is auditing its program to ensure no other patients slipped through the cracks and updating the follow-up appointment process. Caldwell urged those involved to apologize to Mrs. A’s family “for the distress caused by the delay in her cancer diagnosis.”