Health and Disability Commissioner Morag McDowell today released a report finding a district health board in breach of
the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman with a liver
lesion.
The woman presented to the Taranaki District Health Board (TDHB) emergency department with leg pain and swelling. She
was referred for a CT scan which resulted in an incidental finding of a liver lesion, for which further non-urgent
imaging was recommended.
While the woman received timely and appropriate treatment in the emergency department at the time, further follow-up of
the non-urgent liver lesion, in particular non-urgent imaging, was not arranged. Sadly, the woman was later diagnosed
with inoperable cancer of the bile duct.
The Commissioner concluded that the fallibilities of TDHB’s results management system, and the collective failures of
several clinicians to assess the incidental CT scan finding and decide on an appropriate course of action, resulted in
the woman not receiving services with reasonable care and skill.
"The DHB has a duty to provide services with reasonable care and skill, and to have in place adequate systems that
ensure the care provided to her complied with the Code," said Ms McDowell.
"This case highlights vulnerabilities in its systems where, despite apparently reasonable processes and safeguards being
in place, her clearly identified liver lesion was not followed up in a timely manner."
Ms McDowell recommended that TDHB provide an update on its progress towards introducing a system to monitor abnormal
radiology results for emergency department patients, and extending its procedure of notifying abnormal findings to
include after-hours contracted radiologists.
The Commissioner also recommended that TDHB consider introducing a mandatory review of all test results ordered prior to
a patient’s discharge from hospital, to ensure that any follow-up is actioned appropriately before they are discharged.
The full report on case 19HDC01900 is available on the HDC website.